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REPUBLIC OF THE PHILIPPINES)

QUEZON CITY ) S.S.


METRO MANILA )

AFFIDAVIT OF LOSS

I, MA. CONCEPCION O. TIZON, of legal age, Filipino, married,


with residence and postal address at Poblacion Bani, Pangasinan,
Philippines, after having been duly sworn in accordance with law,
depose and say:

1. That I am a holder of the following valid Identification


Cards, to wit:

a. Non-Professional Drivers License No. A07-77-009413; and


b. SSS Identification Card with SS No. 02-0248644-8;

2. That sometime in January 2006, my shoulder bag was


slashed, and for which my wallet was lost including the above-
mentioned Identification Cards;

3. That I exerted diligent efforts to recover and/or retrieve


said Drivers License and SSS Identification Card but all to no avail for
the same were deemed totally lost and beyond recovery;

4. That I am executing this Affidavit to attest the truth of the


foregoing facts.

IN WITNESS WHEREOF, I have hereunto set my hand this 27 th day


of March 2006 at Quezon City, Metro Manila, Philippines.

MA. CONCEPCION O. TIZON


(Affiant)

JURAT

SUBSCRIBED AND SWORN to before me this 27th day of March


2006 at Quezon City, Metro Manila, Philippines, affiant exhibited to me
her Community Tax Certificate No. 15008064 issued on January 10,
2006 at Bani, Pangasinan, and Tax Identification Card with Taxpayers
Identification No. 121-123-333.

Doc. No. ____;


Page No. ____; Notary Public
Book No. ____;
Series of 2006.