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REPUBLIC OF THE PHILIPPINES )

PROVINCE OF NORTHERN SAMAR )S.S.


MUNICIPALITY OF CATARMAN)

AFFIDAVIT OF LOSS

I, IMELDA MEGENIO, of legal age, Filipino, and residing at Brgy.


Galutan, Catarman, Northern Samar, Philippines, after being sworn to in
accordance with law, depose and say:

That I am a lawful holder of 4Ps Identification Card and ATM card,


which unfortunately lost or misplaced by me;

That despite of diligent search and efforts to locate the said


Identification and ATM Card, I could not find such, that I now believe that
the same were lost beyond recovery;

That as such, I am executing this Affidavit of Loss to attest to the truth


of the foregoing and to support my application for the issuance of a new 4Ps
Identification Card ATM Card, in lieu of the one that was lost, and for
whatever legal purpose this may serve best.

Affiant sayeth naught.

IN WITNESS WHEREOF, I have hereunto set my hand this


________in the Municipality of Catarman, Province of Northern Samar,
Philippines.

IMELDA MEGENIO
Affiant

SUBSCRIBED AND SWORN to before me this ___________, in


Catarman, Northern Samar, Philippines. The affiant is known to me to be the
same person who executed and personally signed the foregoing instrument
before me and avowed under penalty of law to the whole truth of the
contents of said instrument.

Doc. No._____;
Page No._____;
Book No._____;
Series of 2015.