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REPUBLIC OF THE PHILIPPINES)

QUEZON CITY ) SS.

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AFFIDAVIT OF LOSS

I, DONNA LEA BELTRAN-ACASIO married, of legal age, Filipino and residing at Block 7 Lot
14 Garcia St. Hobart Village, Brgy. Kaligayahan Quezon City , after having been duly sworn to
in accordance with law, depose and state:

1. That I am the owner of the lost Cellular Phone OPPO A37, SSS ID with no. 06-3136378, PAG-
IBIG ID, PHILHEALTH ID, NTC ID of my Husband (Jessie Acasio) ATM CARD issued by BDO, PS
BANK, AUB and COCO LIFE health insurance ID;

2. That sometime on MARCH 1, 2018, that the said lost Cellular Phone OPPO A37, SSS ID with no.
06-3136378, PAG-IBIG ID, PHILHEALTH ID, NTC ID of my Husband (Jessie Acasio) ATM
CARD issued by BDO, PS BANK, AUB and COCO LIFE health insurance ID was inadvertently lost
together with my bag;

3. That even with diligent effort to locate the was said lost Cellular Phone OPPO A37, SSS ID with
no. 06-3136378, PAG-IBIG ID, PHILHEALTH ID, NTC ID of my Husband (Jessie Acasio) ATM
CARD issued by BDO, PS BANK, AUB and COCO LIFE health insurance ID proved futile;

4. That I am executing this affidavit to attest the truth of the foregoing facts.

IN WITNESS WHEREOF, I have hereunto affixed my signature this day 5th of March 2018 at
Quezon City, Philippines.

DONNA LEA BELTRAN-ACASIO


AFFIANT

SUBSCRIBED AND SWORN TO before me, a notary public in and for Quezon City this day 5th of
March 2018 in Quezon City.

Notary Public
MCLE 6th Compliance (June 4-8, 2018)-
Waiting for Certificate