Republic of the Philippines ]

City of Tagbilaran ] S.S.

AFFIDAVIT OF LOSS

I, AGATONICA ROLLORAZO, Filipino, of legal age, single and a

resident of Totolan, Dauis, Bohol, Philippines, after having been duly sworn to
in accordance with law, do hereby depose and say:

1. That I am a plan holder of the St. Peter Life Plan, Inc.;

2. That as such, I was issued a Certificate of Full Payment by the

said St. Peter Life Plan, Inc., however, it was lost / misplaced;

3. That despite diligent efforts exerted to find and recover the same,
my efforts proved futile as its whereabouts still could not be
ascertained, hence, I considered it to be lost, for all intents and
purposes;

4. That I execute this affidavit voluntarily to attest to the truth of the

foregoing statements and for whatever legal purpose it may serve.

IN WITNESS WHEREOF, I hereunto set my hand this

__________________ at Tagbilaran City, Bohol, Philippines.

AGATONICA ROLLORAZO
Affiant

SUBSCRIBED AND SWORN to before me this

__________________ at Tagbilaran City, Bohol, Philippines.