REPUBLIC OF THE PHILIPPINES )

Quezon City ) S.S.

AFFIDAVIT OF LOSS

I, Eddieson M. Salvador, of legal age and residing/with address at Blk 44 Lot 8 Anahaw St.,
Amparo Vilage, Caloocan City, under oath, state:

1. THAT on October 4, 2012 while riding on a bus from SM Fairview to Baclaran, my

wallet was pick-pocketed without my knowledge;

2. THAT my wallet contained my ID’s (Driver’s License, Community Tax Certificate,

advantage card, MRT stored value ticket and small amount of money);

3. THAT I exerted diligent efforts to locate my wallet or identify the culprit but to no avail
and I therefore considered the same as lost and can no longer be found;

4. THAT I am executing this Affidavit to attest to the truth of the foregoing facts and to use
the same for whatever legal purpose it may serve.

IN WITNESS WHEREOF, I hereunto affix my signature this October 8, 2012 at Quezon City.

EDDIESON M. SALVADOR
Affiant

SUBSCRIBED AND SWORN to before me this October 8, 2012 at Quezon City, Affiant
exhibiting to me his SSS ID bearing No. 33-6585781-4 issued at Manila.

NOTARY PUBLIC

Doc No. _____

Page No. ____
Book No. ____
Series of 2012.