REPUBLIC OF THE PHILIPPINES}

MUNICIPALITY OF PATEROS } S.S.

METRO MANILA }

AFFIDAVIT OF LOSS

I, JEN GREY KYREE ESPINA, of legal age, Filipino and resident of

Alley 14, P. Rosales Street, Brgy. Sta. Ana, Pateros, Metro Manila, after
having been duly sworn, does hereby depose and say –

1. That I am a holder of the following personal properties, to wit:

a. SSS ID
b. Philhealth ID
c. PAG-IBIG ID
d. TIN ID
e. PSA Records
f. Diploma – National College of Science and Technology
g. Transcript of Record
h. Good Moral Certificate
i. Metrobank ATM Card
j. BDO ATM Card

2. That I am keeping the aforesaid personal documents/IDs at our

residence located at the above stated address, however, on July 15,
2022, our house was seized by fire including the above listed
personal documents.

3. I exerted diligent effort to locate my personal belongings above

listed, but proved futile; hence, I considered the same as beyond
retrieve.

4. That the lost of my personal properties was beyond my control.

5. I am executing this Affidavit of Loss to attest the truth of the

foregoing and for whatever legal purposes this may serve.

IN WITNESS WHEREOF, I affixed my signature this August 11,

2022 at Pateros, Metro Manila.

JEN GREY KYREE ESPINA

Affiant

SUBSCRIBED AND SWORN to before me this August 11, 2022 at

Pateros, Metro Manila with Affiant affixing her signature in my presence
and within my notarial jurisdiction.

Doc. No. ____

Page No. ____
Book No. ____
Series of 2022