Republic of the Philippines )

City of Lucena ) Sc.

AFFIDAVIT OF LOSS

I, BERNADETTE B. VALENZUELA, widow, of legal age, Filipino

and a resident of Marktown subd., Brgy. Ibabang Dupay, Lucena City,
after having been duly sworn to in accordance with law hereby depose
and state:

That I am the surviving wife of PABLITO M.

VALENZUELA, who died on December 20, 2022 in Manila;

That my deceased husband is the holder of OFFICIAL

RECEIPT OF FIRST PAYMENT CONTRIBUTION;

That said the above-mentioned got misplaced and efforts

to retrieve proved futile;

That in view of the above premises, the same is now

considered irretrievably lost and;

That I am executing this affidavit to attest to the fact of

loss of the above-mentioned OFFICIAL RECEIPT OF FIRST
PAYMENT CONTRIBUTION for the purpose of requesting for
the issuance of a replacement in lieu of the lost one and for
whatever legal purpose this may serve.

IN WITNESS WHEREOF, I have hereunto affixed my signature this

11th day of April 2023 at Lucena City.

BERNADETTE B. VALENZUELA
Declarant

SUBSCRIBED AND SWORN to before me this 11 th day of April

2023 at Lucena City.

Doc. No. ___

Page No. ___
Book No.___
Series of 2023.