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Republic of the Philippines)

Province of Negros Oriental)s.s.


Municipality of Sibulan….)

AFFIDAVIT OF LOSS

THAT I, ANECITA B. CABALUNA, of legal age, Filipino, married, and a resident of


barangay Maslog, Sibulan, Negros Oriental, under oath, do hereby depose and manifest:

That last July 16, 2013, I was in Mt. Carmel Parish Church in Enrique Villanueva,
Siquijor to attend the town fiesta in the said place;

That at around 10:30 o’clock in the morning while I attended the Mass at Mt Carmel
Church I placed my wallet at the pew of the Church, unfortunately, I forgot to get and bring
my said wallet after the mass and I left it where it was placed when I attended the mass;

That I went back to Church after three hours and my wallet could no longer be found;

That what were inside my wallet were the following important document and papers,
to wit:
1. ATM (UCPB)
2. DCCCO Identification Card ID No. 09639-4
3. Non Professional Driver’s License No. GO2-049319
4. Pawn Ticket No. 40506 SG00 9882 of Cebuana Lluihler
5. Cash of Php5,000.00 & $3
6 PHILHEALTH ID

That I have reported the said incident to the Police Station in Enrique Villanueva,
Siquijor and I have exerted all efforts to locate the aforementioned items, but despite diligent
efforts exerted to locate them, the same can no longer be found;

That this affidavit is executed freely and voluntarily just to attest the truthfulness and
veracity of the statements alleged herein.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___day of July,


2013, at Sibulan, Negros Oriental.

ANECITA B. CABALUNA
(Affiant)
CTC NO. 25021807
Issued on January 16, 2013
At Dumaguete City

SUBSCRIBED AND SWORN to before me, this ___day of July 2013, at Sibulan,
Negros Oriental.

TIRSO F. BANQUERIGO
Circuit Trial Judge

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