Affid. of Loss-GSIS

REPUBLIC OF THE PHILIPPINES )
PROVINCE OF LA UNION ) S.S.

CITY OF SAN FERNANDO )
AFFIDAVIT of LOSS
I, _____________, of legal age, married, Filipino and a resident

of____________________ after having been duly sworn to in accordance with law, hereby
depose and state that:
1. I am a staff nurse at the _________________________________
2. That I am a plan holder of the GSIS, with Policy No. ___________, with Business
Partner No______________;
3. That said Policy was kept together with my other files and documents in our home;
4. That however, due to inadvertence, said Policy could not be located anymore;
5. That diligent efforts were exerted to locate said Policy but all such endeavors proved
futile and to no avail, hence the same is now considered lost and at a point beyond
recovery;
6. That said policy contract/s had never been encumbered, pledged, mortgaged or given
as a security to any contract with any person or establishment;
7. That I execute this affidavit to attest to the truth of the foregoing facts based on
personal knowledge and for all legal intents and purposes this may serve.
IN WITNESS WHEREOF, I hereunto set my hand this ___ day of June 2018 at San Fernando
City, La Union, Philippines.
_______________________
Affiant
PRC ID No.____________
Valid until: 04/23/2019
(With picture)
SUBSCRIBED AND SWORN to before me this ___ day of June 2018 at ______________.
Affiant was identified by me through competent evidence of identity.
Doc. No. ____;

Page No. ____;
Book No. ____;
Series of 2018.
AFFIDAVIT of LOSS
I, CORAZON P. ELORIA, of legal age, married, Filipino and a resident of #170 Quinavite,
Bauang, La Union after having been duly sworn to in accordance with law, hereby depose and
state that:
1. I am a staff nurse at the Ilocos Training and Regional Medical Center (ITRMC) at
Barangay Parian, San Fernando City, La Union
2. That I am a plan holder of the GSIS, with Policy No. CM 00002021606, with
Business Partner No. 2000147688;
5. That diligent efforts were exerted to locate said Policy but all such endeavors
proved futile and to no avail, hence the same is now considered lost and at a point
beyond recovery;
6. That said policy contract/s had never been encumbered, pledged, mortgaged or
given as a security to any contract with any person or establishment;
IN WITNESS WHEREOF, I hereunto set my hand this ___ day of June 2018 at San Fernando
CORAZON P. ELORIA
Affiant
Senior Citizen ID No. 16570
Issued on 09/25/2013 at
Bauang, La Union
(With picture)
SUBSCRIBED AND SWORN to before me this ___ day of June 2018 at San Fernando City,
La Union. Affiant was identified by me through competent evidence of identity.
Doc. No. ____;

Page No. ____;
Book No. ____;
Series of 2018.
AFFIDAVIT of LOSS
I, ERLINA G. BANAYAT, of legal age, married, Filipino and a resident of Camansi, San
Fernando City, La Union after having been duly sworn to in accordance with law, hereby depose
and state that:
Barangay Parian, San Fernando City, La Union
2. That I am a plan holder of the GSIS, with Policy No. CM 0000202119, with
Business Partner No. 2000147777;
5. That diligent efforts were exerted to locate said Policy but all such endeavors
proved futile and to no avail, hence the same is now considered lost and at a point
beyond recovery;
6. That said policy contract/s had never been encumbered, pledged, mortgaged or
given as a security to any contract with any person or establishment;
IN WITNESS WHEREOF, I hereunto set my hand this ____ day of June 2018 at San Fernando
ERLINA G. BANAYAT
Affiant
PRC ID No. 0149498
(With picture)
SUBSCRIBED AND SWORN to before me this ____ day of June 2018 at San Fernando City,
Doc. No. ____;

Page No. ____;
Book No. ____;
Series of 2018.
AFFIDAVIT of LOSS
I, KIER STEVEN J. DE GUZMAN, of legal age, single, Filipino and a resident of Tanqui,
San Fernando City, La Union after having been duly sworn to in accordance with law, hereby
Barangay Parian, San Fernando City, La Union and as an employee thereof, I was
issued a Land Bank of the Philippines (LBP) ATM card;
9. I kept said LBP ATM card in my wallet along with my money, which I place inside my
bag and carry along every time I go to work;
10. Said LBP ATM card serves as my payroll account;
11. Sometime in April 5, 2018, I used said LBP ATM card to inquire/check my remaining
balance, and kept the same in my wallet after the transaction and immediately placed
the same inside my bag and went home;
12. However, when I checked my bag, I was surprised to see that my LBP ATM card on
my wallet is gone;
13. It might have been misplaced or unintentionally dropped during the trip or on my
way home;
14. Despite diligent efforts to locate/retrieve said LBP ATM card, the same proved me futile
and in vain. Hence, I now consider said LBP ATM card as lost and beyond recovery;
15. I am certain that the above-described LBP ATM card was neither confiscated nor
transferred to any person or entity, nor used for any unlawful purpose;
16. I am executing this Affidavit of Loss to attest to the truth of all the foregoing and for the
purpose of supporting my request for the issuance of a new LBP ATM card in lieu of
the lost one;
17. Further, I am executing this affidavit for all legal intents and purposes this may serve.
IN WITNESS WHEREOF, I hereunto set my hand this ___ day of April, 2018 at San Fernando
KIER STEVEN J. DE GUZMAN

Affiant
PRC ID No. 0776739
(With picture)
SUBSCRIBED AND SWORN to before me this ___ day of April, 2018 at San Fernando City,
Doc. No. ____;

Page No. ____;
Book No. ____;
Series of 2018.
AFFIDAVIT of LOSS
I, CYNTHIA M. TIU, of legal age,married, Filipino and a resident of 157 Gen. Ortega St.,
Ilocanos Norte, San Fernando City, La Union after having been duly sworn to in accordance with
law, hereby depose and state that:
18. I am a Nurse V (Clinical) at the Ilocos Training and Regional Medical Center (ITRMC)
at Barangay Parian, San Fernando City, La Union and as an employee thereof, I was
issued a GSIS Unified Multi-Purpose I.D. (UMID) card;
19. I kept said GSIS UMID card in my wallet along with my money, which I place inside
my bag and carry along every time I go to work;
20. Sometime in January 2018, I went to Coast Savers Inc. (CSI), San Fernando City, La
Union branch to buy some groceries, I used my LBP Debit Card, present said GSIS
UMID card as a proof of identification and kept the same in my wallet after the
transaction and immediately placed the same inside my bag and went home;
21. However, when I checked my bag, I was surprised to see that my GSIS UMID card on
my wallet is gone;
way home;
23. Despite diligent efforts to locate/retrieve said GSIS UMID card, the same proved me
futile and in vain. Hence, I now consider said GSIS UMID card as lost and beyond
recovery;
24. I am certain that the above-described GSIS UMID card was neither confiscated nor
purpose of supporting my request for the issuance of a new GSIS UMID card in lieu of
the lost one;
IN WITNESS WHEREOF, I hereunto set my hand this ____ day of April, 2018 at San Fernando
CYNTHIA M. TIU
Affiant
PRC ID No. ________
Valid until: __________
(With picture)
SUBSCRIBED AND SWORN to before me this ____ day of April, 2018 at San Fernando City,
Doc. No. ____;

Page No. ____;
Book No. ____;
Series of 2018.
AFFIDAVIT of LOSS
I, WINSTON JAKE P. ETALIN, of legal age, single, Filipino and a resident of Tanqui, San
Fernando City, La Union after having been duly sworn to in accordance with law, hereby depose
and state that:
27. I am a resident doctor at the Ilocos Training and Regional Medical Center (ITRMC) at
30. Sometime in January 28, 2018, I used said LBP ATM card to inquire/check my
remaining balance, and kept the same in my wallet after the transaction and
immediately placed the same inside my bag and went home;
my wallet is gone;
way home;
the lost one;
IN WITNESS WHEREOF, I hereunto set my hand this 30th day of January, 2018 at San
Fernando City, La Union, Philippines.
WINSTON JAKE P. ETALIN

Affiant
PRC ID No. 0130523
(With picture)
SUBSCRIBED AND SWORN to before me this 30th day of January, 2018 at San Fernando
City, La Union. Affiant was identified by me through competent evidence of identity.
Doc. No. ____;

Page No. ____;
Book No. ____;
Series of 2018.
AFFIDAVIT of LOSS
I, HANSEL L. DURO, of legal age, single, Filipino and a resident of Poblacion Norte,
Salcedo, Ilocos Sur after having been duly sworn to in accordance with law, hereby depose and
state that:
1. At present, I am a resident doctor at the Ilocos Training and Regional Medical

Center (ITRMC), Parian, San Fernando City, La Union, and the owner of a
Samsung cellphone with Globe sim bearing the mobile number 09152003137;
2. I kept said cellphone in my pocket and carry along every time I travel/commute;
3. On January 6, 2018, I went home and used said cellphone to follow up and
communicate with my patients;
4. However, when I was travelling from Ilocos Sur to the ITRMC, when I needed my
phone, I discovered that it was no longer in my pocket nor in my bag;
5. It might have been misplaced or unintentionally slipped during the stop-over at

Candon City or earlier at the bus stop;
6. Despite diligent efforts to locate/retrieve said cellphone, the same proved me futile
and in vain. Hence, I now consider the said cellphone as lost and beyond recovery;
7. I am certain that the cellphone was neither confiscated nor transferred to any
person or entity, nor used for any unlawful purpose;
8. I am executing this Affidavit of Loss to attest to the truth of all the foregoing and for
the purpose of supporting my request for the issuance of a new Globe sim card
with the same mobile number in lieu of the lost one;
9. Further, I am executing this affidavit for all legal intents and purposes this may
serve.
HANSEL L. DURO
Affiant
Valid ID No. _________
(With picture)
SUBSCRIBED AND SWORN to before me this 30th day of January, 2018 at San Fernando
Doc. No. ____;

Page No. ____;
Book No. ____;
Series of 2018.
AFFIDAVIT of LOSS
I, EDSON C. DE LA CRUZ, of legal age, single, Filipino and a resident of Taberna, Bauang,
La Union, after having been duly sworn to in accordance with law, hereby depose and state that:
37. I am an employee of the Ilocos Training and Regional Medical Center (ITRMC) at
40. Sometime in January 5, 2018, I used said LBP ATM card to inquire/check my
my wallet is gone;
way home;
the lost one;
EDSON C. DE LA CRUZ
Affiant
Agency ID No. 20040801
(With picture)
SUBSCRIBED AND SWORN to before me this 5th day of January, 2018 at San Fernando City,
Doc. No. ____;

Page No. ____;
Book No. ____;
Series of 2018.
AFFIDAVIT of LOSS
I, ROGER P. BAUTISTA, of legal age, single, Filipino and a resident of 137 Pila, Luna, La
Union, after having been duly sworn to in accordance with law, hereby depose and state that:
47. I am an Administrative Assistant under a Contract of Service status at the Ilocos

Training and Regional Medical Training Center (ITRMC) and as an employee thereof,
I was issued a Development Bank of the Philippines (DBP) ATM card;
48. I kept said DBP ATM card in my wallet along with my money, which I place inside my
49. Said DBP ATM card serves as my payroll account;
50. On December 16, 2017, I went to the Mercury Drugs Store, Bacnotan, La Union
Branch to buy some medicines, brought out some cash from my wallet and returned
my wallet in my pocket and immediately placed the same inside my bag and went
home;
51. However, when I checked my bag, I was surprised to see that my DBP ATM card in
my wallet was gone;
52. It might have been misplaced or unintentionally dropped during the transaction at
said drug store or on my way home;
53. Despite diligent efforts to locate/retrieve said DBP ATM card, the same proved me
futile and in vain. Hence, I now consider said DBP ATM card as lost and beyond
recovery;
54. I am certain that the above-described DBP ATM card was neither confiscated nor
purpose of supporting my request for the issuance of a new DBP ATM card in lieu of
the lost one;
IN WITNESS WHEREOF, I hereunto set my hand this 18th day of December, 2017 at San
ROGER P. BAUTISTA
Affiant
TIN: 439-495-375
(With picture)
SUBSCRIBED AND SWORN to before me this 18th day of December, 2017 at San Fernando
Doc. No. ____;

Page No. ____;
Book No. ____;
Series of 2017.
AFFIDAVIT of LOSS
I, CIAN CARLO S. DUMO, of legal age, single, Filipino and a resident of Santiago Sur, San
Fernando City, La Union, after having been duly sworn to in accordance with law, hereby depose and
state that:
57. I am a registered nurse at the Ilocos Training and Regional Medical Center (ITRMC)
at Barangay Parian, San Fernando City, La Union, at the same time a licensed
professional driver, and as a nurse thereof and a private car owner in general, I was
issued a PRC ID and a Professional Driver’s License by the Professional Regulatory
Commission, Manila and the Land Transportation Office, Regional Office I, San
Fernando City, La Union respectively;
58. I kept PRC ID and Driver’s license in my wallet along with my money, which I place
inside my bag and carry along every time I go to work;
59. Said PRC ID and Driver’s license serve as my pass to practice my profession and to
drive my car;
60. On December 12, 2017, I dropped by at the hospital canteen to buy some snacks,
brought out some cash from my wallet and returned my wallet in my pocket, and I
immediately went to the hospital ground where my car was parked and went home;
61. However, upon reaching our house, when I checked my pocket and my bag, I was
surprised to see that my wallet along with my PRC ID, Professional Driver’s license
and some cash were gone;
62. It might have been misplaced or unintentionally dropped at the hospital canteen or
hospital grounds;
63. Despite diligent efforts to locate/retrieve my wallet containing my PRC ID, Driver’s
License and some cash, the same proved me futile and in vain. Hence, I now consider
my wallet with my PRC ID, Driver’s License and some cash as lost and beyond
recovery;
64. I am certain that the above-described PRC ID and Driver’s License were neither
confiscated nor transferred to any person or entity, nor used for any unlawful purpose;
purpose of supporting my request for the issuance of a new PRC ID and Professional
Driver’s License cards in lieu of the lost ones;
CIAN CARLO S. DUMO

Affiant
ANSAP ID Card No. 15-008334
(With picture)
Doc. No. ____;

Page No. ____;
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Series of 2017.
AFFIDAVIT of LOSS
I, MOREEN P. RUBANG, of legal age, single, Filipino and a resident of Panicsican, San Juan,
La Union, after having been duly sworn to in accordance with law, hereby depose and state that:
70. On December 11, 2017, I went to the Costsaver’s Supermarket, Inc. (CSI), San
Fernando City, La Union Branch and used said LBP ATM card to inquire/check my
my wallet is gone;
way home;
the lost one;
MOREEN P. RUBANG
Affiant
TIN: 474-609-372
(With picture)
Doc. No. ____;

Page No. ____;
Book No. ____;
Series of 2017.
AFFIDAVIT of LOSS
I, MARIBEL M. DUMO, of legal age, married, Filipino and a resident of Pagdaraoan, San
state that:
80. Sometime in November 20, 2017, I used said LBP ATM card to inquire/check my
my wallet is gone;
way home;
the lost one;
IN WITNESS WHEREOF, I hereunto set my hand this 1st day of December, 2017 at San
MARIBEL M. DUMO
Affiant
Agency ID No. 20040801
(With picture)
SUBSCRIBED AND SWORN to before me this 1st day of December, 2017 at San Fernando
Doc. No. ____;

Page No. ____;
Book No. ____;
Series of 2017.

AFFIDAVIT of LOSS
I, MA. MARGARET S. ACEBEDO, of legal age, single, Filipino and a resident of Tanqui, San
state that:
90. Sometime in October 6, 2017, I used said LBP ATM card to inquire/check my
my wallet is gone;
way home;
the lost one;
IN WITNESS WHEREOF, I hereunto set my hand this 9th day of October, 2017 at San
MA. MARGARET S. ACEBEDO

Affiant
PRC ID NO. 0135200
Valid Until: 10/09/2019
(With picture)
SUBSCRIBED AND SWORN to before me this 9th day of October, 2017 at San Fernando City,
Doc. No. ____;

Page No. ____;
Book No. ____;
Series of 2017.

AFFIDAVIT of LOSS
I, DIONICIO R. BAGAOI, of legal age, married, Filipino and a resident of Tamurong 1st,
Candon City, Ilocos Sur, after having been duly sworn to in accordance with law, hereby depose and
state that:
99. Sometime in the late afternoon of September 26, 2017, I used said LBP ATM card to
withdraw my remaining salary for the month of September, however, said LBP ATM
card was captured by the LBP Machine;
100. I patiently waited for about ten minutes hoping to retrieve said LBP ATM card from
the machine, thereafter, decided to go home and to report the incident the following
day;
101. Earlier today, LBP bank agents opened said machine and we discovered that said
LBP ATM card was not inside the machine;
102. It might have been dispensed by the machine after I left the ATM and it might
have been taken by an unknown person who also used the LBP ATM;
103. Despite diligent efforts to locate/retrieve said LBP ATM card, the same proved me
futile and in vain. Hence, I now consider said LBP ATM card as lost and beyond
recovery;
the purpose of supporting my request for the issuance of a new LBP ATM card in lieu
of the lost one;
serve.
IN WITNESS WHEREOF, I hereunto set my hand this 27th day of September, 2017 at San
DIONICIO R. BAGAOI
Affiant
Phil. Driver’s License No. AO4-95-050396
Valid Until: 08/17/18
(With picture)
SUBSCRIBED AND SWORN to before me this 27th day of September at San Fernando City,
Doc. No. ____;

Page No. ____;
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Series of 2017.
AFFIDAVIT of LOSS
I, REY NATANIEL E. PAPA, of legal age, single, Filipino and a resident of Sitio 5, Barangay
Biday, San Fernando City, La Union, after having been duly sworn to in accordance with law, hereby
107. I am the biological father of ASHTON AIZEN B. PAPA, minor, who is a member
of the Philippine Health Insurance Corporation (PHIC) with membership No.
07050865247;
108. On May 11, 2017, I went to the PHIC Coast Saver Inc. (CSI), San Fernando
City, La Union branch to settle my spouse’s due from January to June 2017 and
was issued an official receipt, which I placed inside my wallet;
109. Upon paying the said dues, I returned to the Ilocos Training and Regional
Medical Center where my spouse was admitted;
110. Thereafter, I went to the PHIC Section of the said hospital to settle my spouse’s
bills. However, when I searched for the said PHIC receipt, I can no longer locate
the same;
111. The said official receipt will be used as an attachment for the issuance of
Certificate of Premium Payment from the PHIC Section;
112. It might have been misplaced or unintentionally dropped during the processing
of my spouse’s hospital bill;
113. Despite diligent efforts to locate/retrieve said PHIC official receipt, the same proved
me futile and in vain. Hence, I now consider said PHIC official receipt as lost and
beyond recovery;
114. I am certain that the PHIC official receipt was neither confiscated nor
115. I am executing this Affidavit of Loss to attest to the truth of all the foregoing and
for all legal intents and purposes this may serve.
IN WITNESS WHEREOF, I hereunto set to an oath my hand this 11th day of May, 2017 at San
JOHN MICHAEL A. GACAD

Affiant
Columban Motor Sales Corporation ID No. 1021-13
TIN No. 440-349-198-000
(With picture)
SUBSCRIBED AND SWORN to before me this 11th day of May, 2017 San Fernando City, La
Union. Affiant was identified by me through competent evidence of identity.
Doc. No. ____;

Page No. ____;
Book No. ____;
Series of 2017.
AFFIDAVIT of LOSS
I, ELISSA E. PABILIN, of legal age, married, Filipino and a resident of Dalumpinas Este, San
state that:
116. I am the mother of patient Carl Daniel E. Pabilin, minor, who was admitted at
the Ilocos Training and Regional Medical Center;
117. On June 8, 2017, I went to the Cashier Section of the hospital to settle the bill
of my son, the PhilHealth had already covered the entire amount of my son’s bill.
However, the collecting officer erroneously charged us for Php. 1,000.00 and upon
payment thereof, I was issued an Official Receipt No. 1114786, which I placed
inside my bag;
118. Thereafter, my son was discharged and went home;
119. On June 13, 2017, a staff of the ITRMC informed me that there was an
erroneous billing made by the collecting officer and required the above-described
official receipt for the reimbursement of the amount paid;
120. However, when I searched for the said ITRMC official receipt, I can no longer
locate the same;
121. The said official receipt will be used as an attachment for the reimbursement
of our expenses;
122. It might have been misplaced or unintentionally dropped at home while

organizing our things from the hospital;
123. Despite diligent efforts to locate/retrieve said ITRMC official receipt, the same
proved me futile and in vain. Hence, I now consider said ITRMC official receipt as lost
and beyond recovery;
124. I am certain that the ITRMC official receipt was neither confiscated nor
IN WITNESS WHEREOF, I hereunto set to an oath my hand this 15th day of June, 2017 at
San Fernando City, La Union, Philippines.
ELISSA E. PABILIN
Affiant
PHIC ID No. 05-025443566-7
(With picture)
SUBSCRIBED AND SWORN to before me this 15th day of June, 2017 San Fernando City, La
Doc. No. ____;

Page No. ____;
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Series of 2017.
AFFIDAVIT of LOSS
I, JOHN MICHAEL A. GACAD, of legal age, married, Filipino and a resident of #85 Purok IV,
Tanquigan, San Fernando City, La Union, after having been duly sworn to in accordance with law,
hereby depose and state that:
126. I am the spouse of JOCELINDA P. GACAD who is a member of the Philippine

Health Insurance Corporation (PHIC) with membership No. 07050865247;
127. On May 11, 2017, I went to the PHIC Coast Saver Inc. (CSI), San Fernando
City, La Union branch to settle my spouse’s due from January to June 2017 and
was issued an official receipt, which I placed inside my wallet;
128. Upon paying the said dues, I returned to the Ilocos Training and Regional
Medical Center where my spouse was admitted;
129. Thereafter, I went to the PHIC Section of the said hospital to settle my spouse’s
bills. However, when I searched for the said PHIC receipt, I can no longer locate
the same;
130. The said official receipt will be used as an attachment for the issuance of
Certificate of Premium Payment from the PHIC Section;
131. It might have been misplaced or unintentionally dropped during the processing
of my spouse’s hospital bill;
132. Despite diligent efforts to locate/retrieve said PHIC official receipt, the same proved
me futile and in vain. Hence, I now consider said PHIC official receipt as lost and
beyond recovery;
133. I am certain that the PHIC official receipt was neither confiscated nor
JOHN MICHAEL A. GACAD

Affiant
Columban Motor Sales Corporation ID No. 1021-13
TIN No. 440-349-198-000
(With picture)
Doc. No. ____;

Page No. ____;
Book No. ____;
Series of 2017.
AFFIDAVIT of LOSS
I, FRANCIS DUCUSIN RUPINTA, of legal age, married, Filipino and a resident of Pagdalagan
Sur, Bauang, La Union, after having been duly sworn to in accordance with law, hereby depose and
state that:
135. I am a Filipino, and as a citizen thereof, I was issued a Philippine Passport with
No. OF 037350 which has already expired;
136. I kept said passport in an envelope along with my other files, which I place
inside my bag and carry along every time I travel abroad;
137. Sometime in 2006 to 2007, I traveled to Malaysia to attend an official business

and used said passport;
138. Upon returning to the Philippines, I kept said passport and other files related
thereto in our cabinet;
139. In the month of January 2014, I planned to renovate our house and thus, I
packed and organized our things including said passport;
140. On May 8, 2017, I received an invitation to attend the Health Care Summit
hosted by the Department of Health at Singapore thus, to process my documents
for travel, I searched for my passport inside our house, however, I can no longer
locate the same;
141. I am certain that the above-described Philippine passport was neither

confiscated nor transferred to any person or entity, nor used for any unlawful
purpose;
for the purpose of supporting my request for the issuance of a new Passport
bearing the same number in lieu of the lost one;
serve.
FRANCIS DUCUSIN RUPINTA

Affiant
PRC ID No. 16747
(With picture)
Doc. No. ____;

Page No. ____;
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Series of 2017.
AFFIDAVIT of LOSS
I, MARINA M. PUMARES, of legal age, widow, Filipino and a resident of Sta. Rita East,
Aringay, La Union, after having been duly sworn to in accordance with law, hereby depose and state
that:
144. I am a member of the Pantawid Pamilyang Pilipino Program and as a member

thereof, I was issued a Land Bank of the Philippines (LBP) ATM card;
145. I kept said LBP ATM card in my wallet along with my money, which I place inside
my bag and carry along every time I go to the market;
146. Said LBP ATM card serves as my 4Ps account;
147. Sometime in March 1, 2017, I used said LBP ATM card to inquire/check my
148. However, when I checked my bag, I was surprised to see that my LBP ATM card
was missing
149. It might have been misplaced or unintentionally dropped during the trip or on
my way home;
recovery;
of the lost one;
serve.
IN WITNESS WHEREOF, I hereunto set my hand this 17th day of March, 2017 at San
MARINA M. PUMARES
Affiant
DSWD
(With picture)
SUBSCRIBED AND SWORN to before me this 16th day of March, 2017 San Fernando City,
Doc. No. ____;

Page No. ____;
Book No. ____;
Series of 2017.

AFFIDAVIT of LOSS
I, DIANE MAE O. TUMAPANG, of legal age, single, Filipino and a resident of #40 Bliss
Baraoas Sur, Naguilian, La Union, after having been duly sworn to in accordance with law, hereby
155. I kept said LBP ATM card in my wallet along with my money, which I place inside
my bag and carry along every time I go to work;
157. Sometime in March 9, 2017, I used said LBP ATM card to inquire/check my
immediately placed the same inside my car and went home;
158. However, when I checked my bag, I was surprised to see that my LBP ATM card
on my wallet is gone;
my way home;
recovery;
of the lost one;
serve.
IN WITNESS WHEREOF, I hereunto set my hand this 14th day of March, 2017 at San
DIANE MAE O. TUMAPANG

Affiant
TIN: 939-190-906
(With picture)
SUBSCRIBED AND SWORN to before me this 14th day of March, 2017 San Fernando City,
Doc. No. ____;

Page No. ____;
Book No. ____;
Series of 2017.
AFFIDAVIT of LOSS
I, ELLEN GRACE R. GURTIZA, of legal age, single, Filipino and a resident of Kamagong St.,
Namnama Village, San Fernando, La Union, after having been duly sworn to in accordance with law,
1. I am f a Non-Professional Philippine Driver’s License by the Land Transportation

Office- Regional Office 1 (LTO-RO1), Sevilla, San Fernando City, La Union;
2. Sometime in June 2015, I went to the LTO-RO1 for the renewal of the said license and
was issued an Official Receipt (OR) of the same;
3. I kept said license and OR in my wallet along with my other Identification cards, which
I place inside my bag and carry along every time I go to work;
4. Sometime in December, 2016, I went to Coast Savers Inc. (CSI), San Fernando City,
La Union branch to buy some groceries for the holiday season;
5. However, when I checked my wallet last December 26, 2016, I was surprised to see
that the official receipt for my driver’s license is no longer in my wallet;
6. It might have been dropped during my CSI transaction or surreptitiously taken by

someone who knew where I place said official receipt;
7. Despite diligent efforts to locate/retrieve said OR, the same proved me futile and in
vain. Hence, I now consider the same as lost and beyond recovery;
8. I am certain that the above-described Official Receipt was neither confiscated nor
purpose of supporting my request for the issuance of a certified true copy of my Driver’s
License Official Receipt in lieu of the lost one and as a requirement of my car insurance
claim at the Government Security and Insurance System (GSIS);
IN WITNESS WHEREOF, I hereunto set my hand this 27th day of February, 2017 at San
ELLEN GRACE R. GURTIZA

Affiant
Phil. Driver’s License No. AO4-10-001590
Valid Until: June 22, 2018
(With picture)
SUBSCRIBED AND SWORN to before me this 27th day of February, 2017 San Fernando City,
Doc. No. ____;

Page No.____;
Book No.____;
Series of 2017.

AFFIDAVIT of LOSS
I, LEONIDA P. YAPIT, of legal age, married, Filipino and a resident of #107 Panicsican, San
Juan, La Union, after having been duly sworn to in accordance with law, hereby depose and state that:
issued a GSIS E-card Plus;
12. I kept said GSIS E-card Plus in my wallet along with my other Identification cards,
which I place inside my bag and carry along every time I go to work;
13. Sometime in October 2016, I went to Cebuana Lhuillier, San Fernando City, La Union
branch to get the remittance sent thru via said pawnshop and used my GSIS E-card
Plus as a proof of my identity and immediately kept the same after the transaction;
14. However, when I checked my wallet last December, 2016, I was surprised to see that
my GSIS E-card Plus is no longer in my wallet;
15. It might have been surreptitiously taken by someone who knew where I place said
GSIS E-card Plus;
16. Despite diligent efforts to locate/retrieve said GSIS E-card Plus, the same proved me
futile and in vain. Hence, I now consider the same as lost and beyond recovery;
17. I am certain that the above-described GSIS E-card Plus was neither confiscated nor
purpose of supporting my request for the issuance of a new GSIS E-card Plus in lieu
of the lost one;
LEONIDA P. YAPIT
Affiant
ITRMC ID No. 19880604
(With picture)
Doc. No. ____;

Page No.____;
Book No.____;
Series of 2017.

AFFIDAVIT of LOSS
I, JOHN PAUL D. ALMOITE, of legal age, single, Filipino and a resident of Barangay
Tammocalao, Bacnotan, La Union, after having been duly sworn to in accordance with law, hereby
1. I am an Administrative Assistant I at the Computer Maintenance Technology Office

(CMTO) of the Ilocos Training and Regional Medical Center (ITRMC) at Barangay Parian,
San Fernando City, La Union and as an employee thereof, I was tasked to assist the
purchase of IT supplies and equipment of any office upon valid request;
2. Sometime in October 2016, I purchased the request of E.R. for a Wireless Router
bearing PR No. 16-10-11374 dated October 11, 2016 at Shania Kenny
Merchandise Computer and Gadget Store;
3. I kept said IVT card in my wallet along with my other Identification cards, which I
place inside my bag and carry along every time I go to work;
4. Sometime in September 2015, the ITRMC Nursing Office collected all IVT cards
for nurses and I diligently entrusted said IVT card to the said office;
5. However, when I checked my IVT card at the Nursing Office last February 7, 2017
for renewal of the same, I was surprised to discover that my IVT card is no longer
in their possession;
6. It might have been surreptitiously taken by someone who knew where they place
said IVT card;
7. Despite diligent efforts to locate/retrieve said IVT card, the same proved me futile
and in vain. Hence, I now consider the same as lost and beyond recovery;
8. I am certain that the above-described IVT card was neither confiscated nor
the purpose of supporting my request for the issuance of a new IVT card in lieu of
the lost one;
serve.
JOHN PAUL ALMOITE

Affiant
PRC ID No.___________
(With picture)
Doc. No. ____;

Page No.____;
Book No.____;
Series of 2017.
AFFIDAVIT of LOSS
I, HEIFIL JAY B. DULAY, of legal age, single, Filipino and a resident of Barangay San Fermin,
Caba, La Union, after having been duly sworn to in accordance with law, hereby depose and state
that:
Barangay Parian, San Fernando City, La Union and as a staff nurse thereof, I attended
various seminars and trainings relative to my profession;
165. Sometime in August 2013, I attended and completed the Intravenous Therapy
Training and was issued an Intravenous Therapy (IVT) Card as a proof thereof;
166. I kept said IVT card in my wallet along with my other Identification cards, which I
167. Sometime in September 2015, the ITRMC Nursing Office collected all IVT cards
for nurses and I diligently entrusted said IVT card to the said office;
168. However, when I checked my IVT card at the Nursing Office last February 7, 2017
for renewal of the same, I was surprised to discover that my IVT card is no longer in
their possession;
169. It might have been surreptitiously taken by someone who knew where they place
said IVT card;
170. Despite diligent efforts to locate/retrieve said IVT card, the same proved me futile
and in vain. Hence, I now consider the same as lost and beyond recovery;
171. I am certain that the above-described IVT card was neither confiscated nor
the purpose of supporting my request for the issuance of a new IVT card in lieu of the
lost one;
serve.
HEIFIL JAY B. DULAY

Affiant
PRC ID No.___________
(With picture)
Doc. No. ____;

Page No.____;
Book No.____;
Series of 2017.
AFFIDAVIT of LOSS
I, NORBERTO G. PREPOSE, JR., of legal age, single, Filipino and a resident of Barangay
Ilocanos Sur, San Fernando City, La Union, after having been duly sworn to in accordance with law,
issued a GSIS Unified Multi-Purpose I.D. (UMID) card;
175. I kept said GSIS UMID card in my wallet along with my other Identification cards,
176. Sometime in July 2016, the Philippine Nurses Association (PNA), La Union
Chapter wished to apply and open an account at the Chinabank, San Fernando City,
La Union branch; And as the elected President thereof, I authorized one of the PNA
officers to use said GSIS UMID card for the application and opening of an account at
the Chinabank as a requirement thereto;
177. The PNA, La Union Chapter officer then reported and returned said GSIS UMID
card after the transaction at the Chinabank, San Fernando City, La Union branch;
178. However, when I checked my wallet last January 31, 2017, I was surprised to see
that my GSIS UMID card is no longer in my wallet;
179. It might have been surreptitiously taken by someone who knew where I place said
GSIS UMID card;
180. Despite diligent efforts to locate/retrieve said GSIS UMID card, the same proved
me futile and in vain. Hence, I now consider the same as lost and beyond recovery;
181. I am certain that the above-described GSIS UMID card was neither confiscated
nor transferred to any person or entity, nor used for any unlawful purpose;
the purpose of supporting my request for the issuance of a new GSIS UMID in lieu of
the lost one;
serve.
IN WITNESS WHEREOF, I hereunto set my hand this 1st day of February, 2017 at San
NORBERTO G. PREPOSE, JR.

Affiant
PRC ID No.0209482
(With picture)
SUBSCRIBED AND SWORN to before me this 1st day of February, 2017 San Fernando City,
Doc. No. ____;

Page No.____;
Book No.____;
Series of 2017.

AFFIDAVIT of LOSS
I, VINCENT PAUL M. SUBALA, of legal age, single, Filipino and a resident of Bawanta,
Bauang, La Union, after having been duly sworn to in accordance with law, hereby depose and state
that:
issued a Land Bank of the Philippines (LBP) and Development Bank of the Philippines
(DBP) ATM cards;
185. I kept said LBP and DBP ATM cards in my wallet along with my money, which I
186. Said LBP and DBP ATM cards serves as my payroll and savings accounts
respectively;
187. On January 27, 2017, I used said LBP ATM card to withdraw my remaining salary
for the month of January, 2017, and kept the same in my wallet after the transaction
and immediately placed the same inside my car and went home;
188. However, when I checked my car at around 9:00 in the evening of the same day, I
was surprised to see that my car door is unlocked and my wallet is gone;
189. It might have been surreptitiously taken by someone who knew where I left said
wallet containing my LBP and DBP ATM cards and some cash;
190. Despite diligent efforts to locate/retrieve said wallet along with my LBP and DBP
ATM cards and some cash, the same proved me futile and in vain. Hence, I now
consider said wallet containing my LBP and DBP ATM cards and some cash as lost
and beyond recovery;
191. I am certain that the above-described LBP and DBP ATM card was neither
confiscated nor transferred to any person or entity, nor used for any unlawful purpose;
the purpose of supporting my request for the issuance of a new LBP and DBP ATM
cards in lieu of the lost one;
serve.
VINCENT PAUL M. SUBALA

Affiant
PRC ID No. 0066491
(With picture)
SUBSCRIBED AND SWORN to before me this 30th day of January, 2017 San Fernando City,
Doc. No. ____;

Page No. ____;
Book No. ____;
Series of 2017.

AFFIDAVIT of LOSS
I, ADA CHARISMA A. DAZON, of legal age, single, Filipino and a resident of Parian, San
Fernando City, La Union, after having been duly sworn to in accordance with law, hereby depose
and state that:
194. I am a graduate of Bachelor of Science in Social Work (BSSW) at Saint Louis

University, Baguio City and subsequently passed the 2014 Board Examinations
for Social Work and was issued a Professional Regulatory Commission (PRC) ID
with number 0023137 on September 2015;
195. I kept said PRC ID in my wallet along with my other IDs, which I place inside
my bag and carry along every time I go to work or travel;
196. Sometime in October 2016, I went to Cebu along with some friends and used
said PRC ID as a collateral pass card during the trip;
197. However, when I organized my things at home, I was surprised that my PRC
ID was not in my wallet nor inside my travelling bag;
my way home;
199. Despite diligent efforts to locate/retrieve said PRC ID, the same proved me
200. I am certain that the above-described PRC ID was neither confiscated nor
for the purpose of supporting my request for the issuance of a new PRC ID bearing
the same number in lieu of the lost one;
serve.
IN WITNESS WHEREOF, I hereunto set my hand this ___ day of January, 2017 at San
ADA CHARISMA A. DAZON

Affiant
ITRMC Employee ID No. 20160118
(With picture)
SUBSCRIBED AND SWORN to before me this ___ day of January, 2017 San Fernando
Doc. No. ____;

Page No. ____;
Book No. ____;
Series of 2017.
AFFIDAVIT of LOSS
I, JESICA ROSS O. PASCUA, of legal age, single, Filipino and a resident of Sevilla Sur,
San Fernando City, La Union, after having been duly sworn to in accordance with law, hereby
203. I am a graduate of Bachelor of Science in Social Work (BSSW) at Saint Louis

University, Baguio City and subsequently passed the 2014 Board Examinations
for Social Work and was issued a Professional Regulatory Commission (PRC) ID
with number 0022019 on the same year;
204. I kept said PRC ID in my wallet along with my other IDs, which I place inside
my bag and carry along every time I go to work or at school;
205. As a working-student, I regularly borrow books from the school’s library using
my PRC ID as a pass card;
206. Sometime in November 2016, I went to school to return some borrowed books
and consequently the librarian released my PRC ID and placed the same inside
my bag. Then I rode a Public Utility Jeepney (PUJ) and went home;
207. Sometime in December 2016, I again intended to borrow some books at the
library, however when I searched my PRC ID inside my bag, the same cannot be
found;
208. It might have been misplaced or unintentionally dropped on my way home last
November 2016 or in any other places;
209. Despite diligent efforts to locate/retrieve said PRC ID, the same proved me
210. I am certain that the above-described PRC ID was neither confiscated nor
for the purpose of supporting my request for the issuance of a new PRC ID bearing
the same number in lieu of the lost one;
serve.
IN WITNESS WHEREOF, I hereunto set my hand this ___ day of January, 2017 at San
JESICA ROSS O. PASCUA

Affiant
ITRMC Employee ID No. 2015071667
(With picture)
SUBSCRIBED AND SWORN to before me this ___ day of January, 2017 San Fernando
Doc. No. ____;

Page No. ____;
Book No. ____;
Series of 2017.
AFFIDAVIT of LOSS
I, AVY LORIAN P. BATAC, of legal age, married, Filipino and a resident of 945A River
Road New Milford, New Jersy, after having been duly sworn to in accordance with law, hereby
213. I am a graduate of Bachelor of Science in Nursing (BSN) at Lorma Colleges,

with office address at Barangay Carlatan, City of San Fernando, La Union and as
a graduate thereof, I was issued a Diploma;
214. I kept said Diploma in a folder along with my other files related thereto, which
I place inside my file organizer and carry along every time I apply for a job or for
other related transactions;
215. Sometime in October 2015, my petition for US was granted and immediately
flew thereafter. However, when I organized my things, I was surprised that my
Diploma was not with the files I carried with when I transferred from the Philippines
to the US;
216. It might have been misplaced or unintentionally disposed of after my transfer;
217. Despite diligent efforts to locate/retrieve said Diploma, the same proved me
218. I am certain that the above-described Diploma was neither confiscated nor
for the purpose of supporting my request for the issuance of a new Diploma in lieu
of the lost one;
serve.
IN WITNESS WHEREOF, I hereunto set my hand this ___ day of December, 2016 at San
AVY LORIAN P. BATAC

Affiant
____________________
(With picture)
SUBSCRIBED AND SWORN to before me this ___ day of December, 2016 San Fernando
Doc. No. ____;

Page No. ____;
Book No. ____;
Series of 2016.
AFFIDAVIT
I, DR. EDWIN V. SANCHEZ, of legal age, married, Filipino and the OIC-Medical Center
Chief II of the Ilocos Training and Regional Medical Center (ITRMC) located at Barangay Parian,
San Fernando City, La Union with the same office address, after having been duly sworn to in
accordance with law, hereby depose and state that:
221. The Ilocos Training and Regional Medical Center (ITRMC) is an applicant
for the registration of Treatment/Storage/Disposal (TSD) Facilities for M501
Hazardous Wastes;
222. I, as the representative of the ITRMC am aware and understand all the duties,
responsibilities and accountability to be imposed upon me and my establishment
by such application and as such will be liable for all damages incurred and for any
untoward incident during its actual operation, during treatment of hazardous
wastes and shall be wholly responsible for spill response and clean-up during spills
or accidental leaks including clean-up or remediation of affected areas and
compensation for any environmental damage caused by such spill or leakage of
hazardous wastes;
223. I attest to the truth, accuracy and genuineness of all the information,
documents and records contained and attached to this application and that I and
my establishment shall be liable for any misrepresentation, fraudulent declaration
and all its consequences;
224. I am executing this affidavit as a proof of good faith in complying with the
requirements for securing the abovementioned registration.
IN WITNESS WHEREOF, I hereunto set my hand this ____ day of November, 2016 at
EDWIN V. SANCHEZ, MD.

Affiant
OIC-Medical Center Chief II
Philippine Driver’s License No. N04-83-021217
Valid Until: August 27, 2018
SUBSCRIBED AND SWORN to before me this ______ day of November, 2016 at San
Fernando City, La Union. Affiant was identified by me through competent evidence of identity,
details of which are written below affiant’s name and signature.
Doc. No. ____;

Page No. ____;
Book No. ____;
Series of 2016.

AFFIDAVIT of LOSS
I, BUTCH A. ABUAN, of legal age, married., Filipino and a resident of Pudoc, Bauang, La
Union, after having been duly sworn to in accordance with law, hereby depose and state that:
225. I am an employee of the Ilocos Training and Regional Medical Center (ITRMC)
at Barangay Parian, San Fernando City, La Union and as an employee thereof, I
was issued a GSIS Temporary ID card;
226. I kept said GSIS Temporary ID card in my wallet along with my other
Identification cards, which I place inside my bag and carry along every time I go to
work;
227. Sometime in March 2016, I used said GSIS Temporary ID card for my
application for loan and kept the same in my wallet after the transaction. However,
when I checked my wallet last November 1, 2016, I was surprised to see that my
GSIS Temporary ID card is no longer in my wallet;
228. It might have been surreptitiously taken by someone who knew where I place
said GSIS Temporary ID card;
229. Despite diligent efforts to locate/retrieve said GSIS Temporary ID card, the
same proved me futile and in vain. Hence, I now consider the same as lost and
beyond recovery;
230. I am certain that the above-described GSIS Temporary ID card was neither
purpose;
for the purpose of supporting my request for the issuance of a new GSIS
Temporary ID in lieu of the lost one;
serve.
IN WITNESS WHEREOF, I hereunto set my hand this 9th day of November, 2016 at San
BUTCH A. ABUAN
Affiant
(With picture)
SUBSCRIBED AND SWORN to before me this 9th day of November , 2016 San Fernando
Doc. No. ____;

Page No. ____;
Book No. ____;
Series of 2016.
AFFIDAVIT of LOSS
I, GENEVIEVE P. DUMAGUIN, of legal age, married., Filipino and a resident of #45A,

Barangay Pagudpud, San Fernando City, La Union, after having been duly sworn to in
accordance with law, hereby depose and state that:
233. I am a Filipino Citizen. And as a citizen thereof, I was issued a Philippine

Passport with No. XX5421769;
234. I kept said passport in my pouch along with my other files related thereto, which
I place inside my bag and carry along every time I travel outside La Union;
235. Sometime in April 2012, I visited my sister who lives at Brgy. Calumpang,
Marikina City. However, when I organized my things, I was surprised that my pouch
containing said Philippine passport can no longer be located;
236. It might have been surreptitiously taken by someone whom I bumped on the
way to my sister’s house;
237. Despite diligent efforts to locate/retrieve said Philippine passport, the same
proved me futile and in vain. Hence, I now consider the same as lost and beyond
recovery;
238. I am certain that the above-described Philippine passport was neither

purpose;
for the purpose of supporting my request for the issuance of a new Passport
bearing the same number in lieu of the lost one;
serve.
IN WITNESS WHEREOF, I hereunto set my hand this 4th day of November, 2016 at San
GENEVIEVE P. DUMAGUIN
Affiant
UMID CRN-0111-31986254
(With picture)
SUBSCRIBED AND SWORN to before me this 4th day of November, 2016 San Fernando
Doc. No. ____;

Page No. ____;
Book No. ____;
Series of 2016.
AFFIDAVIT of DISCREPANCY
RE: DATE OF BIRTH
I, CORNELIA S. COBALES of legal age, single, Filipino and a resident of Barangay

Parian, San Fernando City, La Union, after having been duly sworn to on oath in accordance with
law, hereby depose and state that:
1. In my scholastic records, I have been using September 16, 1969 as my

date of birth and celebrating my birthday on the said date with the honest
belief that it was my true and correct date of birth;
2. For several years, I have been using September 16, 1969 as my date of
birth and whenever, I am signing documents requiring the same. However,
sometime in 1992, when I applied for my passport, I obtained a copy of my
birth certificate from the National Statistics Office as one of the
requirements and discovered at that time that my true and correct date of
birth is OCTOBER 16, 1968;
3. Also my date of birth appearing in my Professional Regulation Commission

license was erroneously entered as September 16, 1969, when in truth and
in fact my true and correct birthday is OCTOBER 16, 1968 as indicated in
the copy of my birth certificate issued by the National Statistics Office;
4. I am executing this affidavit to attest to the truth of the foregoing facts and
to explain the discrepancy in my scholastic records, Professional
Regulation Commission license and other records as regards to my date
of birth;
5. Further, I am declaring that from this date hereon I would be using my true
and correct date of birth of OCTOBER 16, 1968 in all my papers, records
and other documents.
IN WITNESS WHEREOF, I hereunto set my hand this 5th day of October 2016 at San
CORNELIA S. COBALES
Affiant
ITRMC Company ID No. 19910901
(With picture)
SUBSCRIBED AND SWORN to before me this 5th day of October 2016 San Fernando
Doc. No. ____;

Page No. ____;
Book No. ____;
Series of 2016.
AFFIDAVIT of LOSS
I, EDNA H. PERALTA of legal age, married., Filipino and a resident of #70 Barangay
Camansi, San Fernando City, La Union, after having been duly sworn to in accordance with law,
241. I am a member of the Tubao Cooperative at Tubao, La Union and as a member

thereof, I was issued a Cooperative Pasbook with No. 29423;
242. I kept said Cooperative Passbook in one of my envelopes along with my other
files related thereto, which I place in my study table at home;
243. Said Cooperative Passbook serves as my membership pass in the

aforementioned cooperative;
244. Sometime in August 2015, I planned to renovate our house and packed and
organized our things. However, when I organized my things, I was surprised that
my envelope containing said Cooperative Passbook can no longer be located;
245. It might have been misplaced or unintentionally disposed of after the said
renovation;
246. Despite diligent efforts to locate/retrieve said cooperative passbook, the same
proved me futile and in vain. Hence, I now consider the same as lost and beyond
recovery;
247. I am certain that the above-described Cooperative Passbook was neither

purpose;
for the purpose of supporting my request for the issuance of a new Cooperative
Passbook bearing the same number in lieu of the lost one;
serve.
EDNA H. PERALTA
Affiant
TIN No. 134226396
(With picture)
SUBSCRIBED AND SWORN to before me this 29th day of September, 2016 San
Fernando City, La Union. Affiant was identified by me through competent evidence of identity.
Doc. No. ____;

Page No. ____;
Book No. ____;
Series of 2016.
AFFIDAVIT of LOSS
I, DONN ALDRIN G. CARIÑO of legal age, single, Filipino and a resident of Barangay
Sevilla, San Fernando City, La Union, after having been duly sworn to in accordance with law,
250. I am an employee of the Ilocos Training and Regional Medical Center (ITRMC)
at Barangay Parian, San Fernando City, La Union and as an employee thereof, I
was issued a Development Bank of the Philippines (DBP) ATM card;
251. I kept said DBP ATM card in my wallet along with my other ID’s and ATM cards,
252. Said DBP ATM card serves as my savings account;
253. Sometime in June 2016, I used said DBP ATM card to pay my bills, and kept
the same in my wallet after the transaction. However, when I checked my wallet
today, I was surprised to see that my DBP ATM card is no longer in my wallet;
254. It might have been surreptitiously taken by someone who knew where I place
said DBP ATM card;
255. Despite diligent efforts to locate/retrieve said DBP ATM card, the same proved
me futile and in vain. Hence, I now consider the DBP ATM card as lost and beyond
recovery;
256. I am certain that the above-described DBP ATM card was neither confiscated
nor transferred to any person or entity, nor used for any unlawful purpose;
for the purpose of supporting my request for the issuance of a new DBP ATM card
in lieu of the lost one;
serve.
DONN ALDRIN G. CARIÑO

Affiant
TIN No. 400-570-049
(With picture)
SUBSCRIBED AND SWORN to before me this 27th day of September, 2016 San
Doc. No. ____;

Page No. ____;
Book No. ____;
Series of 2016.
AFFIDAVIT of LOSS
I, MONIQUE P. PREPOSE of legal age, single, Filipino and a resident of Barangay Sevilla,
San Fernando City, La Union, after having been duly sworn to in accordance with law, hereby
I am an employee of the Ilocos Training and Regional Medical Center (ITRMC) at

issued a Land Bank ATM card, Philippine Veterans Bank (PVB) ATM card, PAG-IBIG
Loyalty card and Bank of the Philippine Islands (BPI) ATM and credit cards;
259. Further, as a citizen of the Philippines, I was issued a Voter’s ID;
260. I kept said Land Bank ATM card, PVB ATM card, PAG-IBIG Loyalty card, BPI
ATM and credit cards and Voter’s ID in my wallet, which I place inside my bag and
carry along every time I go to work;
261. On or about 12:00 o’clock noon of April 8, 2016, I left my bag at the office and
had my lunch at another place. However, when I returned to my table where I
placed my bag and wallet, I was surprised to see that my wallet is no longer in my
bag;
262. It might have been surreptitiously taken by someone who entered the office;
263. Despite diligent efforts to locate/retrieve said wallet in which my Land Bank
ATM card, PVB ATM card, PAG-IBIG Loyalty card, BPI ATM and credit cards and
Voter’s ID were kept, the same proved me futile and in vain. Hence, I now consider
the said Land Bank ATM card, PVB ATM card, PAG-IBIG Loyalty card, BPI ATM
and credit cards and Voter’s ID as lost and beyond recovery;
264. I am certain that the above-described Land Bank ATM card, PVB ATM card,
PAG-IBIG Loyalty card, BPI ATM and credit cards and Voter’s ID were neither
purpose;
for the purpose of supporting my request for the issuance of a new Land Bank
ATM card, PVB ATM card, PAG-IBIG Loyalty card, BPI ATM and credit cards and
Voter’s ID in lieu of the lost ones;
serve.
IN WITNESS WHEREOF, I hereunto set my hand this 15th day of April, 2016 at San
MONIQUE P. PREPOSE
Affiant
TIN No. 309-674-373
(With picture)
SUBSCRIBED AND SWORN to before me this 15th day of April, 2016 San Fernando City,
Doc. No. ____;
Page No. ____;
Book No. ____;
Series of 2016.

AFFIDAVIT of LOSS
I, MARK PHILIP AGAG SALINAS, of legal age, married, Filipino and a resident of
Canaoay, San Fernando City, La Union, after having been duly sworn to in accordance with law,
267. I am employed as Nurse II at the Ilocos Training and Regional Medical Center
(ITRMC) at Barangay Parian, San Fernando City, La Union and I am a member of
the Association of Nursing Service Administrators of the Philippines (ANSAP);
268. As a member of the ANSAP, I was issued an identification card bearing the
Number 14-1124;
269. I kept said ANSAP card in my wallet, which I place inside my bag and carry
along;
270. However, sometime February 29, 2016, when I searched my ANSAP I.D. in
my wallet which I intend to renew, I was surprised to see that it was no longer in
my wallet;
271. I might have left it in another place or it might have slipped from my wallet;
272. Despite diligent efforts to locate/retrieve the said ANSAP ID, the same proved
me futile and in vain. Hence, I now consider the said ANSAP ID as lost and beyond
recovery;
273. I am certain that the above-described ANSAP ID is neither confiscated nor

for the purpose of supporting my request for the issuance and renewal of a new
ANSAP ID in lieu of the lost one;
serve.
IN WITNESS WHEREOF, I hereunto set my hand this 5th day of April 2016 at San
MARK PHILIP A. SALINAS

Affiant
PRC ID No. 0568508
Issued 8/26/2009
Valid until 9/14/ 2018
(With picture)
SUBSCRIBED AND SWORN to before me this 5TH day of April 2016 San Fernando City,
Doc. No. _136_;

Page No. _28_;
Book No. __I__;
Series of 2016.

AFFIDAVIT of LOSS
I, HELEN GRACE B. HIPONA of legal age, single, Filipino and a resident of Barangay
Paringao, Bauang, La Union, after having been duly sworn to in accordance with law, hereby
276. I am an employee of Ilocos Training and Regional Medical Center (ITRMC) at

issued a GSIS e-card;
277. I kept said e-card in my wallet, which I place inside my bag and carry along
every time I go to work;
278. On or about 5:30 in the late afternoon of March 8, 2016, for the purpose of
withdrawing some cash at the ATM of Land Bank stationed at the hospital, I
inserted said card;
279. I waited patiently for my e-card and cash to come out on the said Land Bank
machine, but it took me some time, so I cancelled the transaction;
280. However, neither the said e-card nor my money came out from the machine;
281. Despite diligent efforts to wait for the said GSIS e-card to come out, the same
proved me futile and in vain. Hence, I now consider the said e-card as lost and
beyond recovery;
282. I am certain that the above-described e-card is neither confiscated nor

for the purpose of supporting my request for the issuance of a new GSIS e-card
in lieu of the lost one;
serve.
IN WITNESS WHEREOF, I hereunto set my hand this ____ day of March, 2016 at San
HELEN GRACE B. HIPONA Affiant

Unified Multi-Purpose ID No. 0111-0447372-3
(With picture)
SUBSCRIBED AND SWORN to before me this ___ day of March, 2016 San Fernando
Doc. No. ____;

Page No. ____;
Book No. ____;
Series of 2016.
AFFIDAVIT of LOSS
I, CROMWEL M. MACAZO, of legal age, single, Filipino and a resident of Barangay San
Blas, Bangar, La Union, after having been duly sworn to in accordance with law, hereby depose
and state that:

issued a Land Bank ATM card;
286. I kept said ATM card in my pouch, which I place inside my gym bag and carry
along every time I go to Theta’s Gym for my scheduled Zumba exercise;
287. On or about 6 o’clock to 7 o’clock in the evening of February 24, 2016, as I

attended to the Zumba exercise, I left said bag with the above-mentioned ATM
card on the bench beside our session hall;
288. However, when I returned to the bench where I placed my bag, I was surprised
to see that it was no longer in the place where I left it;
289. It might have been surreptitiously taken by someone who entered the session
hall;
290. Despite diligent efforts to locate/retrieve the said bag with my Land Bank ATM
Card, the same proved me futile and in vain. Hence, I now consider the said bank
card as lost and beyond recovery;
291. I am certain that the above-described bank card is neither confiscated nor
for the purpose of supporting my request for the issuance of a new Land Bank
ATM Card in lieu of the lost one;
serve.
CROMWEL M. MACAZO
Affiant
PRC ID No. 42407
Issued January 12, 2015
Valid until March 28, 2018
(With picture)
SUBSCRIBED AND SWORN to before me this ____ day of February, 2016 San Fernando
Doc. No. ____;

Page No. ____;
Book No. ____;
Series of 2016.
AFFIDAVIT of LOSS
and state that:

issued a Land Bank ATM card and is the owner of Cherry Mobile cellphone with
Smart sim bearing the mobile number 09182710366;
11. I kept said ATM card and cellphone in my pouch, which I place inside my gym bag
and carry along every time I go to Theta’s Gym for my scheduled Zumba exercise;
12. On or about 6 o’clock to 7 o’clock in the evening of February 24, 2016, as I attended
to the Zumba exercise, I left said bag with the above-mentioned items on the bench
beside our session hall;
13. However, when I returned to the bench where I placed my bag, I was surprised to
see that it was no longer in the place where I left it;
14. It might have been surreptitiously taken by someone who entered the session hall;
15. Despite diligent efforts to locate/retrieve the said bag with my Land Bank ATM Card
and cellphone, the same proved me futile and in vain. Hence, I now consider the
said bank card and cellphone as lost and beyond recovery;
16. I am certain that the above-described bank card and cellphone were neither
purpose;
the purpose of supporting my request for the issuance of a new Land Bank ATM
Card and Smart sim card with the same mobile number in lieu of the lost one;
serve.
CROMWEL M. MACAZO
Affiant
PRC ID No. 42407
(With picture)
SUBSCRIBED AND SWORN to before me this ____ day of March, 2016 San Fernando
Doc. No. ____;

Page No. ____;
Book No. ____;
Series of 2016.
AFFIDAVIT of LOSS
and state that:

issued a Land Bank ATM card and is the owner of Samsung Corby II cellphone
with Globe sim bearing the mobile number 09277782439;
20. I kept said ATM card and cellphone in my pouch, which I place inside my gym bag
and carry along every time I go to Theta’s Gym for my scheduled Zumba exercise;
21. On or about 6 o’clock to 7 o’clock in the evening of February 24, 2016, as I attended
to the Zumba exercise, I left said bag with the above-mentioned items on the bench
beside our session hall;
22. However, when I returned to the bench where I placed my bag, I was surprised to
see that it was no longer in the place where I left it;
23. It might have been surreptitiously taken by someone who entered the session hall;
24. Despite diligent efforts to locate/retrieve the said bag with my Land Bank ATM Card
and cellphone, the same proved me futile and in vain. Hence, I now consider the
said bank card and cellphone as lost and beyond recovery;
25. I am certain that the above-described bank card and cellphone were neither
purpose;
the purpose of supporting my request for the issuance of a new Land Bank ATM
Card and Globe sim card with the same mobile number in lieu of the lost one;
serve.
CROMWEL M. MACAZO
Affiant
PRC ID No. 42407
(With picture)
SUBSCRIBED AND SWORN to before me this ____ day of March, 2016 San Fernando
Doc. No. ____;

Page No. ____;
Book No. ____;
Series of 2016.
AFFIDAVIT of LOSS
I, ALEJANDRINO LEAL, of legal age, single, Filipino and a resident of Pallogan, Tagudin,
Ilocos Sur, after having been duly sworn to in accordance with law, hereby depose and state that:
1. I am employed as a construction worker and is the owner of the following: Driver’s

License, Union Bank ATM card, Samsung A-7 cellphone and 10,000.00 pesos
cash;
2. I kept said license, ATM card, cellphone and cash in my bag, which I carry along
every time I go to the construction site;
3. On or about 5 o’clock in the late afternoon of February 18, 2016, I left said bag
with the above-mentioned items, padlocked inside the construction workers’
quarter;
4. However, when I returned to our quarter where I placed my bag on or about 7

o’clock in the morning of February 19, 2016, I was surprised to see that it was no
longer in the place where I left it;
5. It might have been surreptitiously taken by someone who entered the construction
workers’ quarter;
6. Despite diligent efforts to locate/retrieve the said bag with driver’s license, Union
Bank ATM Card, Samsung A-7 cellphone and 10,000.00 pesos cash , the same
proved me futile and in vain. Hence, I now consider the said license, bank card,
cellphone and cash as lost and beyond recovery;
7. I am certain that the above-described license, bank card, cellphone and cash were
neither confiscated nor transferred to any person or entity, nor used for any
unlawful purpose;
the purpose of supporting my request for the issuance of a new Driver’s license,
Union Bank ATM Card in lieu of the lost one;
serve.
IN WITNESS WHEREOF, I hereunto set my hand this ____ day of __________, 2016 at
ALEJANDRINO LEAL
Affiant
ID No. ____________________
Date issued ________________
(With picture)
SUBSCRIBED AND SWORN to before me this ____ day of ____________, 2016 San
Doc. No. ____;

Page No. ____;
Book No. ____;
Series of 2016.

Affid. of Loss-GSIS

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Affid. of Loss-GSIS

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REPUBLIC OF THE PHILIPPINES )

PROVINCE OF LA UNION ) S.S.

I, _____________, of legal age, married, Filipino and a resident

1. I am a staff nurse at the _________________________________

Doc. No. ____;

Doc. No. ____;

Doc. No. ____;

10. Said LBP ATM card serves as my payroll account;

KIER STEVEN J. DE GUZMAN

Doc. No. ____;

Doc. No. ____;

29. Said LBP ATM card serves as my payroll account;

WINSTON JAKE P. ETALIN

Doc. No. ____;

1. At present, I am a resident doctor at the Ilocos Training and Regional Medical

5. It might have been misplaced or unintentionally slipped during the stop-over at

Doc. No. ____;

39. Said LBP ATM card serves as my payroll account;

Doc. No. ____;

47. I am an Administrative Assistant under a Contract of Service status at the Ilocos

49. Said DBP ATM card serves as my payroll account;

Doc. No. ____;

CIAN CARLO S. DUMO

Doc. No. ____;

69. Said LBP ATM card serves as my payroll account;

Doc. No. ____;

79. Said LBP ATM card serves as my payroll account;

Doc. No. ____;

PROVINCE OF LA UNION ) S.S.

89. Said LBP ATM card serves as my payroll account;

MA. MARGARET S. ACEBEDO

Doc. No. ____;

PROVINCE OF LA UNION ) S.S.

98. Said LBP ATM card serves as my payroll account;

Doc. No. ____;

JOHN MICHAEL A. GACAD

Doc. No. ____;

118. Thereafter, my son was discharged and went home;

122. It might have been misplaced or unintentionally dropped at home while

Doc. No. ____;

126. I am the spouse of JOCELINDA P. GACAD who is a member of the Philippine

JOHN MICHAEL A. GACAD

Doc. No. ____;

137. Sometime in 2006 to 2007, I traveled to Malaysia to attend an official business

141. I am certain that the above-described Philippine passport was neither

FRANCIS DUCUSIN RUPINTA

Doc. No. ____;

144. I am a member of the Pantawid Pamilyang Pilipino Program and as a member

146. Said LBP ATM card serves as my 4Ps account;

Doc. No. ____;

PROVINCE OF LA UNION ) S.S.

156. Said LBP ATM card serves as my payroll account;

DIANE MAE O. TUMAPANG

Doc. No. ____;

1. I am f a Non-Professional Philippine Driver’s License by the Land Transportation

6. It might have been dropped during my CSI transaction or surreptitiously taken by

ELLEN GRACE R. GURTIZA

Doc. No. ____;

PROVINCE OF LA UNION ) S.S.

Doc. No. ____;

PROVINCE OF LA UNION ) S.S.

1. I am an Administrative Assistant I at the Computer Maintenance Technology Office

JOHN PAUL ALMOITE