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REPUBLIC OF THE PHILIPPINES)

CITY OF DAVAO ) SS.

AFFIDAVIT OF LOSS

I, APPLE MAE J. SHIROMA, Filipino, of legal age, and a resident of Davao City,
Philippines, after having been duly sworn in accordance with law, hereby depose and say:

1. I am the same person and identical person who caused the execution of this instrument;

2. That in the year 2016, I applied for a St. Peter’s Life Plan Policy which was duly
registered under my name with Contract no L16224746A;

3. That sometime on November 2017, I discovered that the Original Copy of the St. Peter’
Life Plan Policy was lost in my room where I kept it;

4. Efforts were exerted to locate the Original Copy of the Policy, but
despite diligent search, it could not be found and the same is now beyond recovery;

5. That I am executing this instrument to inform concerned office for the lost of the said
document and attest to the truth and veracity of the same;

IN WITNESS WHEREOF, I have hereunto affixed my signature this 21st day of June
2018 at Davao City, Philippines.

APPLE MAE J. SHIROMA


Driver’s License No. L02-11-005351
Expiry Date: April 12, 2022
Affiant

SUBCRIBED AND SWORN TO before me this 21st day of June 2018 in Davao
City, Philippines, affiant exhibiting to me her competent evidence of identity written below her
name.

________________________
Notary Public

Doc. No. ____;


Page No. _____;
Book No. ____;
Series of 2018.