REPUBLIC OF THE PHILIPPINES )

PROVINCE OF NORTHERN SAMAR )S.S.

MUNICIPALITY OF CATARMAN )
x------------------------------------------x

AFFIDAVIT OF LOSS

I, _______________, of legal age, Filipino and with residence and

postal address at San Isidro, Northern Samar, Philippines, after having been
duly sworn to in accordance with law depose and say:

That I am a lawful holder of Landbank ATM Card, Metro Bank ATM

Card, Vaccination Card, TIN Card, Driver’s License and PhilHealth ID which
were unfortunately lost by me and diligent efforts and search of the same
proved futile.

That I am executing this affidavit to attest to the truth of the foregoing

circumstance and for the purpose of informing the authorities concerned so
that a replacement will be issued in my favor.

IN WITNESS WHEREOF, I have hereunto set my hand this

________, in Catarman, Northern Samar, Philippines.

______________________
Affiant

SUBSCRIBED AND SWORN to before me this ___________, in

Catarman, Northern Samar, Philippines, by affiant who is known to me to be
the same person who executed and personally signed the foregoing
instrument before me and avowed under penalty of law to the whole truth of
the contents of said instrument.

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 2021.