REPUBLIC OF THE PHILIPPINES )

) S.S.

AFFIDAVIT OF LOSS

I, , of legal age, Filipino citizen, and resident of after being duly sworn in
accordance with law, hereby depose and state under oath:

1. That I am the lawful and legal spouse of a. as evidenced by our Marriage Contract;

2. That my husband is a member of a Membership Certificate;

3. That my husband died on as evidenced by his Death Certificate;

4. That as the legal beneficiary of the death benefits of my deceased spouse,

5. That I have made a diligent search and inquiry to locate the lost certificate but to no
avail. It is irretrievably lost and cannot be recovered;

6. That the loss of the said certificate was not due to any negligence, willful act, or
omission on my part;

7. That I have executed this affidavit for whatever legal purpose it may serve, and to
attest to the truth of all the foregoing statement.

IN WITNESS WHEREOF, I have hereunto signed my name this ____ day of

____________ in _____________, Philippines.

Affiant

SUBSCRIBED AND SWORN to before me this _____ day of September

_______ in ____________, Philippines. Affiant exhibited to me his competent evidence
of identity as ____________________.

Notary Public

Doc. No____;
Page No. ___;
Book No. ___;
Series of ____.