REPUBLIC OF THE PHILIPPINES)

PROVINCE OF LA UNION
) Sc.
MUNICIPALITY OF TUBAO
)
x-------------------------x

AFFIDAVIT OF LOSS

We, RONDEL SION BERNARDEZ and JULIE RIVERA

MAGLAYA, both of legal ages, both single, Filipino citizens and
residents of Francia Sur, Tubao, La Union after having been duly sworn
to in accordance with law, do hereby depose and state, that:
1. We are the natural and biological parents of RON
KENLEY MART MAGLAYA BERNARDEZ, who was
born on October 19, 2007 at La Union Medical Center,
Agoo, La Union;
2. In fact, the La Union Medical Center (LUMC), Agoo, La
Union issued a form to register the birth of our son, Ron
Kenley Mart;
3. But we forgot to submit the said form to the Local Civil
Registrar of Agoo, La Union;
4. When the time came to register the birth of our son, we
failed to locate the said form given to us;
5. That we exerted our best efforts to locate the same but to
no avail;
6. That the said form is now considered lost and beyond
recovery;
7. That we are executing this Affidavit to attest to the truth
of all the foregoing facts, as a requirement in our
application for the delayed registration of Birth of our son
with the office of the Local Civil Registrar of Agoo, La
Union, and for all legal intents and purposes it may serve.
IN WITNESS WHEREOF, we have hereunto set our hands this
13th day of June 2016 at Tubao, La Union, Philippines.
RONDEL SION BERNARDEZ
MAGLAYA
Affiant
Postal ID No. 4080409

JULIE RIVERA
Affiant

SUBSCRIBED AND SWORN to before me this 13th day of June

2016 at Tubao, La Union by the affiants appearing personally and who
are known to me to be the same persons who executed this affidavit.

Doc. No.: 420;

Page No.:
84;
Book No.: VIII;
Series of 2016.

ATTY. JOONEE RANDYL E. RIVERA

Notary Public until December 31, 2016
Aspiras Highway, Francia Sur, Tubao, La
Union
Roll No. 61766, TIN 929-347-628
PTR No. 643362; 01-04-16, Tubao, LU
IBP Life Member No. 012553; 01-02-14,
SFLU
Commission No. ANC-2014-11