Affidavit of Loss

REPUBLIC OF THE PHILIPPINES)
PROVINCE OF _________________ : S.S.

MUNICIPALITY OF _____________ )
AFFIDAVIT OF LOSS
WITH UNDERTAKING
I, ARNALDO P. DIZON, of legal age, Filipino, married, with residence and

postal address at Km. 101 McArthur Highway, Brgy. Anupul, Bamban, Tarlac
2317, Philippines, after being sworn to in accordance with law, freely depose
and say:
THAT
1. I am the registered owner of the motor vehicle described below as, to

wit:
MAKE : Mitsubishi - Fuso

BODY TYPE : DROPSIDE
SERIES : CANTER
DENOMINATION : Utility Vehicle
FUEL : DIESEL
PLATE No. : XBF828
ENGINE No. : ____________________
CHASSIS No. : ____________________
MVFILE No. : 131200000232820
2. As proof of ownership of the above described vehicle, I was issued by

the Land Transportation Office (LTO), East Avenue, Quezon City,
Official Receipt (OR) No. 266976323 as proof of payment and
Certificate of Registration (CR) No. 4283584-4 from LTO, Mabalacat
Extension Office, Mabalacat, Pampanga;
3. Said documents while in my possession were misplaced and could

no longer be found in spite of diligent efforts in locating them;
4. Said documents were not confiscated by any government authorities

in violation of R.A. 4136 and other related laws;
5. I shall assume any responsibility or liability if in any event the said

documents were used with or without my knowledge for whatever
illicit transactions;
6. I am executing this affidavit to attest to the veracity of my

statements and to support the same in its request for duplicate
copies of the lost OR & CR at the Land Transportation Office,
Mabalacat Extension Office, Mabalacat, Pampanga, where it was
previously issued;
7. I bind myself criminally, civilly and administratively liable and will
assume full responsibility of any 3rd party claim, and I hereby hold
the LTO or any of its employees free any liability arising from any
claim for damages as a result of the approval of the registration of
the motor vehicle and or issuance of the replacement of OR & CR;
IN WITNESS WHEREOF, I have hereunto affixed my signature this 24 th

day of June 2014 at ____________________________, Philippines.
ARNALDO P. DIZON
Affiant
TIN: 234-409-680-000
SUBSCRIBED AND SWORN to before me this 24th day of June 2014 at

__________________________, Philippines, affiant exhibited to me his Tax
Identification Number duly noted above below his name and signature, and is
known to me and to me known to be the same person who executed the
foregoing instrument and acknowledged to me that the same is his free act and
deed and that he voluntarily executed the same and understood all the
contents thereof.
WITNESS MY HAND AND SEAL.
Doc. No. ______;

Page No. ______;
Book No. _____;
Series of 2014.
PROVINCE OF TARLAC : S.S.
MUNICIPALITY OF BAMBAN )
AFFIDAVIT OF LOSS
I, MARICAR LOPEZ DE GUZMAN, of legal age, Filipino, single, with

residence and postal address at Brgy. Anupul, Bamban, Tarlac 2317, Philippines,
after having been duly sworn to in accordance with law, do hereby depose and say:
THAT
1. Sometime on October 09, 2013, I pawned my 3.10 grams 18k Pulcera

Rope with the Cebuana Lhuillier Pawnshop, Bamban Branch, Bamban,
Tarlac, Philippines, in the amount of Php4,700.00;
2. Consequently, I was issued a Pawn Ticket by said Cebuana Lhuillier

Pawnshop with Pawn Ticket No. 6034856009184 with expiry date of
February 03, 2014;
3. On January 15, 2014, I found out that the Pawn Receipt issued to me
by Cebuana Lhuillier Pawnshop was missing and all efforts to locate
the same has been in vain;
4. I am executing this Affidavit of Loss to attest to the truth of all the

foregoing and to manifest under oath that I pawned my 3.10 grams 18k
Pulcera Rope with the said Cebuana Lhuillier Pawnshop, Bamban
Branch, Bamban, Tarlac 2317, Philippines; and that I inadvertently lost
the Pawn Ticket issued to me by Cebuana Lhuillier Pawnshop;
IN WITNESS WHEREOF, I have hereunto affixed my signature this 21 st day

of January 2014 at Bamban, Tarlac 2317, Philippines.
MARICAR LOPEZ DE GUZMAN

Affiant
Postal ID No. 42181731
Valid Until: 06 Oct. 2016
SUBSCRIBED AND SWORN to before me this 21 st day of January 2014 at

Bamban, Tarlac, Philippines, affiant exhibited to me her positive identification duly
noted above below her name and signature, is known to me and to me known to be
the same person who executed the foregoing instrument and acknowledged before
me that the same is her free act and deed and that she voluntarily executed the
same and understood all the contents thereof.
ATTY. ARNALDO P. DIZON

Roll No. 20706
Notary Public-Province of Tarlac
My Commission Expires December 31, 2014
PTR No. 2877209, 01-03-14, Bamban, Tarlac
IBP O. R. No. 881746, 01-03-14, Tarlac Chapter
MCLE Compliance Certificate No. IV-0022714/12-19-13
Doc. No. 170;
Page No. 34;
Book No. XII;
Series of 2014.
AFFIDAVIT OF LOSS
I, JESSICA D. AMURAO, of legal age, Filipino, single, with residence and

postal address at Cope Subdivision, Brgy. Alfonso, Concepcion, Tarlac 2316,
Philippines, after having been duly sworn to in accordance with law, do hereby
depose and say:
THAT
5. I am a registered voter and a holder of a Commission on Election

(COMELEC) Identification Card;
6. On December 16, 2013, while I was riding a passenger tricycle at

Brgy. San Roque, Tarlac City, I inadvertently lost my hand bag
containing my said COMELEC ID and among other things;
7. Since then, I tried to locate and retrieved my said COMELEC ID but

all my efforts were in vain;

foregoing; to declare the said COMELEC ID issued in my name as
lost and null and void, and to request the Commission of Election to
issue a replacement for the same;

day of January 2014 at Bamban, Tarlac, Philippines.
JESSICA D. AMURAO
Affiant
Dominican College of Tarlac
Student ID No. AB-0173
SUBSCRIBED AND SWORN to before me this 14 th day of January 2014

at Bamban, Tarlac, Philippines, affiant exhibited to me her positive
identification duly noted above below her name and signature, is known to me
and to me known to be the same person who executed the foregoing instrument
and acknowledged before me that the same is her free act and deed and that
she voluntarily executed the same and understood all the contents thereof.

Roll No. 20706
Doc. No. 146; My Commission Expires December 31, 2014
Page No. 30; PTR No. 2877209, 01-03-14, Bamban, Tarlac
Book No. XII; IBP O. R. No. 881746, 01-03-14, Tarlac Chapter
Series of 2014. MCLE Compliance Certificate No. IV-
0022714/12-19-13
AFFIDAVIT OF LOSS
I, GISELLE SIBAL-TAKAHASHI, of legal age, Filipino, with residence and

postal address at Sitio Mano, Brgy. Anupul, Bamban, Tarlac 2317, Philippines,
after being sworn to in accordance with law, freely depose and say: THAT
1. I am the legal and biological mother of minor MIYUKI TAKAHASHI,

who was born on November 05, 2011, a copy of her Certificate of
Live Birth is hereto attached as Annex A to form an integral part
hereof;
2. My daughter MIYUKI is a holder of a Japanese Passport No.

MS8921944, issued on December 16, 2011, valid until December
16, 2016, issued by the Ministry of Foreign Affairs of Japan, a copy
of which is hereto attached as Annex B to form an integral part
hereof;
3. Sometime in August 2012, while I and my daughter was in a

restaurant somewhere in Manila, Philippines, I inadvertently left my
bag containing my daughter`s Japanese Passport and her milk
container;
3. Since then, I tried to locate and retrieved my bag but all my efforts
were in vain;

foregoing; to declare the aforesaid Japanese Passport of my minor
daughter MIYUKI TAKAHASHI with No. MS8921944 as lost and null
and void; and to request the Ministry of Foreign Affairs of Japan and
the Consulate Office of the Philippines in Japan to issue a
replacement for said passport in the name in my minor daughter
MIYUKI TAKAHASHI;
IN WITNESS WHEREOF, I have hereunto affixed my signature this ______

day of January 2013 at _____________________, Philippines.
GISELLE SIBAL-TAKAHASHI
Affiant
Passport No. XX1295711
Valid Until: ____________
SUBSCRIBED AND SWORN to before me this _____ day of January 2013

at _____________________, Philippines, affiant exhibited to me his positive
identification duly noted above below his name and signature, known to
me and to me known to be the same person who executed foregoing instrument
and acknowledged to me that the same is his free act and deed and that he
voluntary executed the same and understood all the contents thereof.
Doc. No. _____;

Page No. _____;
Book No. ____;
Series of 2013.
MUNICIPALITY OF CAPAS )
AFFIDAVIT OF LOSS
I, GAUDENCIO ADLAI A. DIZON, of legal age, Filipino, married to APPLE

KAY SANTOS-DIZON, with residence and postal address at No. 100, Brgy. San
Roque, Bamban, Tarlac 2317, Philippines, after being sworn to in accordance
with law, freely depose and say:
THAT
1. I am a depositor and holder of a Savings Account Passbook with

Account No. 504-15-007388-1 of the Rural Bank of Angeles, Capas
Branch, Capas, Tarlac;
2. Sometime in March 2012, while I was about to update my Savings

Account, I discovered that my said Passbook was missing from the
drawer of my dress cabinet where I usually keep the same;
3. Since then, I tried to locate and retrieved my said Passbook but all
my efforts were in vain;

foregoing; to declare my said Savings Account Passbook No. 504-15-
007388-1 of the Rural Bank of Angeles, Capas Branch, Capas,
Tarlac, as lost and null and void, and to request the Rural Bank of
Angeles, Capas Branch, Capas, Tarlac, to issue a replacement for the
same in my name.

day of August 2012 at Capas, Tarlac 2317, Philippines.
GAUDENCIO ADLAI A. DIZON

Affiant
Postal ID No.: 6578230
Valid Until: 05-14-13
SUBSCRIBED AND SWORN to before me this _____ day of August 2012 at

Capas, Tarlac, Philippines, affiant exhibited to me his positive identification
duly noted above below his name and signature, known to me and to me known
to be the same person who executed foregoing instrument and acknowledged to
me that the same is his free act and deed and that he voluntary executed the
WITNESS MY HAND SEAL.

Doc. No. ____;
Page No. ____;
Book No. ____;
Series of 2012.
AFFIDAVIT OF LOSS
I, WILSON SIBAL, JR., of legal age, Filipino, married, with residence and
postal address at Sto. Domingo I, Capas, Tarlac 2315, Philippines, after being
sworn to in accordance with law, freely depose and say:
THAT
1. I am a registered member of PhilHealth and a holder of a PhilHealth

Membership Identification Card;
2. Sometime in February 2012, while I was at a Supermarket, my

PhilHealth ID was inadvertently loss without noticing the same;
3. Since then, I tried to locate and retrieved my PhilHealth ID but all

my efforts turned in vain;

foregoing, and to request the PhilHealth to declare my PhilHealth ID
as lost and null and void, and to issue a replacement for the same.

day of May 2012 at Bamban, Tarlac 2317, Philippines.
WILSON SIBAL, Jr.

Affiant
Drivers Licence No.: C11-77-027633
Valid Until: June 19, 2014
SUBSCRIBED AND SWORN to before me this _____ day of May 2012 at

Bamban, Tarlac, Philippines, affiant exhibited to me his positive identification
duly noted above below his name and signature, known to me and to me known
to be the same person who executed foregoing instrument and acknowledged to
me that the same is his free act and deed and that he voluntary executed the

Roll No. 20706
MCLE Compliance Certificate No. III-0001473/01-09-09
Doc. No. _____;

Page No. _____;
Book No. X;
Series of 2012.
AFFIDAVIT OF LOSS
I, JULY MOLATO AGUSTIN, of legal age, Filipino, with residence and postal
address at Salangi, Capas, Tarlac 2315, Philippines, after being duly sworn to in
accordance with law, freely depose and say:
THAT
1. I am the registered owner of the certain motor vehicle, which more

particularly described as follows:
MAKE : RUSI
YEAR MODEL : 2010
PLATE No. : 6113 RQ
MOTOR No. : RW152FMHBA601110
SERIAL/CHASSIS No. : RWCLXPGA9A9611110
2. Said motor vehicle was issued a Plate No. 6113 RQ by the Land
Transportation Authority (LTO).
3. On June 12, 2012, while I was riding said motor vehicle at Brgy. Patling,
Capas, Tarlac, upon reaching my point of destination, I was surprise that
said plate number was missing;
4. Since then, I tried to locate and retrieved my said motor vehicle`s Certificate
of Registration but all my efforts turned in vain;
5. I am executing this Affidavit of Loss to attest to the truth of all the foregoing;
to declare the lost Plate No. 6113 RQ as loss and request the Land
Transportation Office (LTO) to issue a new one for the same;
IN WITNESS WHEREOF, I have hereunto affixed my signature this 13 th day of

June 2012 at Bamban, Tarlac 2317, Philippines.
JULY MOLATO AGUSTIN

Affiant
ID No.: _____________________
Valid Until: _____________
SUBSCRIBED AND SWORN to before me this _____ day of June 2012, affiant
exhibited to me his positive identification duly noted above below his name and
signature, known to me and to me known to be the same person who executed the
foregoing instrument and acknowledged to me that the same is his free act and deed
and that he voluntarily executed the same and understood all the contents thereof.

Roll No. 20706
Doc. No. _____; My Commission Expires December 31, 2012
Page No. _____; PTR No. 1555954, 01-02-12, Bamban, Tarlac
Book No. X; IBP O. R. No. 773829, 01-02-12, Tarlac Chapter
Series of 2012. MCLE Compliance Certificate No. III-0001473/01-09-09
JOINT AFFIDAVIT OF LOSS
We:
ELMER RIVERA, of legal age, Filipino, single, with residence and postal address at
0231 Casmor Phase 1, Mabiga, Mabalacat, Pampanga 2010,
- and -
EDGAR RIVERA, of legal age, Filipino, married to LIZA TUAZON-RIVERA, with

residence and postal address at 103 Rizal Avenue, Brgy. San Roque, Bamban, Tarlac 2317,
Philippines, after being sworn to in accordance with law, freely depose and say:
THAT
1. We are depositors of ALLIED BANKING CORPORATION, Mabalacat Branch,

Mabalacat, Pampanga, where we maintain a US DOLLAR ACCOUNT under the following
account numbers, to wit:
a) Account Number 002-327-000-00003278004672, with a deposit in the

amount of US DOLLARS: SIX THOUSAND and/100; and
b) Account Number 002-327-000-00003278005199, with a deposit in the

amount of THREE THOUSAND (3,000.00) US DOLLAR;
2. On April 14, 2009, we were issued Foreign Currency Certificate of Time

Deposit (FXCY CTD) by the Allied Banking Corporation, Mabalacat Branch, Mabalacat,
Pampanga, to wit:
a) Account Number 002-327-000-00003278004672/FXCY CTD Number

0075777 in the amount of US DOLLARS: SIX THOUSAND and xx/100 (US$
5,000.00) with maturity date on April 29, 2010; and
b) Account Number 002-327-000-00003278005199/FXCY CTD Number

0075824 in the amount of US DOLLARS: THREE THOUSAND and xx /100
(US$3,000.00) with maturity date on April 01, 2011;
Photo copies of said FXCY CTD are hereto attached as Annexes A and B
respectively, both of which are made integral part hereof;
3. Sometime in November 2010, we inadvertently loss said FXCY CTD and

efforts to locate and retrieve the same since then have been in vain;
4. We are executing this Affidavit of Loss to attest to the truth of all the
foregoing; to request the ALLIED BANKING CORPORATION, Mabalacat Branch, Mabalacat,
Pampanga, to declare said lost FXCY CTD as null and void, and to issue new ones in lieu
thereof;
Page 1 of 2
IN WITNESS WHEREOF, we have hereunto affixed our signatures this 26 th day of
January 2011 at Bamban, Tarlac 2315, Philippines.
ELMER RIVERA EDGAR RIVERA

Affiant Affiant
Drivers License No. 96-094336 Drivers License C01-08-000001
Valid Until: October 11, 2013 Valid Until: 01-18-2013
SUBSCRIBED AND SWORN to before me this 26 th day of January 2011 at Bamban,

Tarlac, Philippines, affiants exhibited to me their positive identifications duly noted above
below their names and signatures, known to me and to me known to be the same persons
who executed foregoing instrument and acknowledged to me that the same is their free act
and deed and that they voluntary executed the same and understood all the contents
thereof.

Roll No. 20706
Doc. No. 440;

Page No. 88;
Book No. V;
Series of 2011.
AFFIDAVIT OF LOSS
I, RICHARD L. TUAZON, of legal age, Filipino, married, with residence and

postal address at Brgy. Anupul, Bamban, Tarlac 2317, Philippines, after being
sworn to in accordance with law, freely depose and say:
THAT
1. I am a Pre-Paid Subscriber of SMART Communications with Subscriber

Identification Module (SIM) and SMART Money Card Number
09302907758;
2. On January 15, 2013, while I was buying in a store at Mabalacat,

Pampanga, I accidentally left my cellular phone where my SMART SIM
and SMART Money Card with Number 09302907758 was inserted;
3. Since then, I tried to locate and retrieved my said cellular phone but all
my efforts turned in vain;

foregoing; to declare my SMART SIM and SMART Money Card with
Number 09302907758 as lost; and to request the SMART
Communications to retain the number of my lost SIM Card to my newly
bought SMART SIM Card;
IN WITNESS WHEREOF, I have hereunto affixed my signature this 17 th day

of January 2013 at Bamban, Tarlac 2317, Philippines.
RICHARD L. TUAZON
Affiant
SSS ID No. 3344006411
SUBSCRIBED AND SWORN to before me this 17 th day of January 2013,

affiant exhibited to me his positive identification duly noted above below his name
and signature, and is known to me and to me known to be the same person who
executed the foregoing instrument and acknowledged to me that the same is his
free act and deed and that he voluntarily executed the same and understood all
the contents thereof.

Roll No. 20706
Doc. No. 28;
Page No. 06;
Book No. XI;
Series of 2013.
AFFIDAVIT OF LOSS
I, SUSAN GABUTAN y ARTATES, of legal age, Filipino, single, with residence and
postal address at Lourdes Park, Bamban, Tarlac 2317, Philippines, after being sworn to in
accordance with law, freely depose and say: THAT
1. Sometime in the year 1996, I applied for an Overseas Job through an

Employment Agency whose main Office is in Ermita, Metro Manila, Philippines;
2. The Manager of said Employment Agency requested me to leave and entrust to

her my passport, identification cards, and other equally important documents
related to my application for an Overseas Job;
3. Unfortunately, the said Employment Agency suddenly closed, thus, I was not
able to retrieve my employment documents, principal among which is my said
passport;
4. Since then, all efforts to locate the personnel of said agency and to recover my
said employment documents have been in vain;
5. I am executing this Affidavit of Loss to attest to the truth of all the foregoing; to
secure a new PASSPORT from the Department of Foreign Affairs; and to declare
my lost PASSPORT as null and void.

October 2009 at Bamban, Tarlac 2317, Philippines.
SUSAN GABUTAN y ARTATES

Affiant
CTC No.: CCI2009 02162799
Issued On: 07-16-09/Bamban, Tarlac
SUBSCRIBED AND SWORN to before me this 19 th day of October 2009 at Bamban,

Tarlac, Philippines, affiant exhibited to me her positive identification duly noted above
below her signature, known to me and to me known to be the same person who executed
foregoing Affidavit of Loss and acknowledged to me that the same is her free act and deed
and that she voluntary executed the same and understood all the contents thereof.

Roll No. 20706
Book No. IV; IBP O. R. No. 684972, 01-05-09, Tarlac Chapter
AFFIDAVIT OF LOSS
I, WILSON SIBAL, JR., of legal age, Filipino, married, with residence and
postal address at Brgy. Sto. Domingo I, Capas, Tarlac 2315, Philippines, after
being sworn to in accordance with law, freely depose and say:
THAT
8. Sometime on February 2012, while I was riding a Public Utility Jeep

route Capas to Tarlac City, my wallet contain my PHILHEALTH
Identification Card fell from my hip pocket;
9. Since then, I tried to locate and retrieved my said wallet but all my
efforts turned in vain;
10. I am executing this affidavit to attest to the truth of all the

foregoing, and to request PHILHEALTH to declare my Identification
Card as lost, to declare the same as null and void, and to issue a
replacement for the same.

day of April 2012 at Bamban, Tarlac 2317, Philippines.
WILSON SIBAL, Jr.

Affiant
Drivers Licence No.: C11-77-027633
Valid Until: June 19, 2014
SUBSCRIBED AND SWORN to before me this 28 th day of May 2011,

affiant exhibited to me his positive identification duly noted above below his
name and signature, and is known to me and to me known to be the same
person who executed the foregoing instrument and acknowledged to me that
the same is his free act and deed and that he voluntarily executed the same
and understood all the contents thereof.

Roll No. 20706
Doc. No. 478;

Page No. 70;
Book No. VII;
Series of 2011.

AFFIDAVIT OF LOSS
I, ABEL B. MANGUERRA, of legal age, Filipino, married to WILMA AGUILAR-

MANGUERRA, with residence and postal address at Brgy. San Rafael, Bamban, Tarlac,
Philippines, after being sworn to in accordance with law, freely depose and say:
THAT
1. On September 18, 2009, while I was on my way to work, my wallet fell from my
hip pocket containing my Drivers Licence and other equally important
identification cards;
2. Since then, I tried to locate and retried my wallet but all my efforts turned in
vain;
3. I am executing this affidavit to attest to the truth of all the foregoing and to
request the Land Transportation Office to declare my lost Drivers Licence as
null and void, and to issue a replacement Drivers License in my favor;

September 2009 at Bamban, Tarlac 2317, Philippines.
ABEL B. MANGUERRA
Affiant
VIN: 6902-0120A-B0367ABM10001-1
SUBSCRIBED AND SWORN to before me this 28 th day of September 2009, affiant

exhibited to me his positive identification duly noted above below his name and signature,
and is known to me and to me known to be the same person who executed the foregoing
instrument and acknowledged to me that the same is his free act and deed and that he
voluntarily executed the same and understood all the contents thereof.

Roll No. 20706
Doc. No. ____;

Page No. ____;
Book No. IV;
Series of 2009.
AFFIDAVIT OF LOSS
I, MARK PANGILINAN DE VERO, of legal age, Filipino, single, with residence

and postal address at 257 Blk. 2, Brgy. Anupul, Bamban, Tarlac 2317, Philippines,
after being sworn to in accordance with law, freely depose and say: THAT
1. On August 29, 2012, at 1:30 oclock in the morning, while I was waiting for
a ride along the McArthur Highway at Brgy. Dolores, City of San Fernando,
Pampanga, I was approached by an unknown person who immediately
declared a holdup and thereafter, forcibly took my bag containing my SM
Pampanga Mall Identification (ID) Card, SM Appliance Center ID Card, SM
Borrower`s ID, Health Card issued by the City of San Fernando, Pampanga,
Cellular Phone with Globe SIM Card No. 0916-310-0445 and Cash;
2. After getting all my valuables, the robber ran away leaving me awe-stricken.
To avoid trouble, I did not try to run after him for fear of bodily harm;
3. I am executing this affidavit to attest to the truth of all the foregoing; to

request the management of SM Pampanga, SM Appliance Center to declare
my lost SM Pampanga Mall ID, SM Appliance Center ID Card, SM Borrower`s
Card and my Globe SIM Card as null and void, and to issue a new one in my
name.

August 2012 at Bamban, Tarlac 2317, Philippines.
MARK PANGILINAN DE VERO

Affiant
Driver`s License No.: C11-08-003532
SUBSCRIBED AND SWORN to before me this 30th day of August 2012, affiant
exhibited to me his positive identification duly noted above below his name and
signature, and is known to me and to me known to be the same person who executed
the foregoing instrument and acknowledged to me that the same is his free act and
deed and that he voluntarily executed the same and understood all the contents
thereof.

Roll No. 20706
Book No. X; IBP O. R. No. 773829, 01-02-12, Tarlac Chapter
AFFIDAVIT OF LOSS
I, CRISTINA V. DIZON, of legal age, Filipino, single, with residence and postal
address at Sitio Pandan, Brgy. Anupul, Bamban, Tarlac 2317, Philippines, after having
been duly sworn to in accordance with law, do hereby depose and say:
THAT
9. Sometime in October 28, 2010, I pawned my Sony Ericson k770i Cellphone with
the Cebuana Lhuillier Pawnshop, Bamban Branch, Bamban, Tarlac 2317,
Philippines, in the amount of Php1,200.00;
10. Consequently, I was issued a Pawn Ticket by said Cebuana Lhuillier Pawnshop
with Pawn Ticket No. 6034856002577 with expiry date of February 28, 2011;
11. Sometime in December 13, 2010, I found out that the Pawn Receipt issued to
me by Cebuana Lhuillier Pawnshop was missing and all efforts to locate the
same has been in vain;
12. I am executing this Affidavit of Loss to attest to the truth of all the foregoing and
to manifest under oath that indeed, I pawned my Sony Ericson k770i Cellphone
with the said Cebuana Lhuillier Pawnshop, Bamban Branch, Bamban, Tarlac
2317, Philippines;
IN WITNESS WHEREOF, I have hereunto affixed my signature this 23 rd day of

December 2010 at Bamban, Tarlac 2317, Philippines.
CRISTINA V. DIZON
Affiant
SSS ID No.: 02-27602294
SUBSCRIBED AND SWORN to before me this 23rd day of December 2010, affiant is
known to me and to me known to be the same person who executed the foregoing
instrument and acknowledged to me that the same is her free act and deed and that she

Roll No. 20706
PTR No. 0708548, 01-05-10 Bamban, Tarlac
Doc. No. 780;

Page No. 76;
Book No. V;
Series of 2010.
AFFIDAVIT OF LOSS
I, JUANITO S. ONG, of legal age, Filipino, single, with residence and postal address
at San Roque, Bamban, Tarlac 2317, Philippines, after being sworn to in accordance with
law, freely depose and say: THAT
1. I am the registered owner of a parcel of land situated at Barrio Mabiga and

Mauaque, Municipality of Mabalacat, Province of Pampanga, Philippines,
covered and described by Transfer Certificate of Title No. 175638, a copy of
which is hereto attached as Annex A and made an integral part hereof;
2. Sometime in January 2011, when I was inquiring at Sun Cellular, Metro Town
Mall, Tarlac City, Philippines, I inadvertently left my envelop containing my
Transfer Certificate of Title No. 175638, and all efforts to locate the same since
then has been in vain;
3. I certify that the ORIGINAL COPY of said TCT is available at the Office of the
Register of Deeds of the City of Angeles;
4. I caused the registration of this Affidavit of Loss with the Office of the Register
of Deeds of the City of Angeles;
5. I am executing this Affidavit of Loss to attest to the truth of all the foregoing
statements, and to secure an Owner`s Duplicate of TCT No. 175638 from the
Register of Deeds of the City of Angeles, after proper court proceedings.
IN WITNESS WHEREOF, I have hereunto affixed my signature this 2 nd day of May

2011 at Bamban, Tarlac, Philippines.
JUANITO S. ONG
Affiant
Drivers License No. N05-73-020177
SUBSCRIBED AND SWORN to before me this 2nd day of May 2011, affiant is known
to me and to me known to be the same person who executed the foregoing instrument and
acknowledged to me that the same is his free act and deed and that he voluntarily
executed the same and understood all the contents thereof.

Roll No. 20706
Book No. VII;
Series of 2011.
AFFIDAVIT OF LOSS
I, NOLAN R. TOLENTINO, of legal age, Filipino, married, with residence and postal
address at Brgy. Anupul, Bamban, Tarlac, Philippines, after being sworn to in accordance
with law, freely depose and say:
THAT
1. Sometime in the month of July, I bought a 6SM Dyna Power Battery from
Winfred Tire Supply located at Angeles City, Pampanga, Philippines, bearing
Serial Number 0437551 and with a warranty for 6 months reckoned from July
2008 or up to December 2008.
2. Sometime last July, I inadvertently lost the Official Receipt issued to me by

Winfred Tire Supply together with the Warranty Slip and all efforts to locate the
same since then up to the present time has been in vain.
3. I am executing this Affidavit of Loss to attest to the truth of all the foregoing and
to secure a replacement for said battery to Winfred Tire Supply in pursuant to
their warranty.

September 2008 at Bamban, Tarlac, Philippines.
NOLAN R. TOLENTINO
Affiant
SSS No. 03-3454617-5
SUBSCRIBED AND SWORN to before me this 17 th day of September 2008, affiant is

known to me and to me known to be the same person who executed the foregoing
instrument and acknowledged to me that the same is his free act and deed and that he

Roll No. 20706
PTR No. 3926087-J, 01-02-08, Bamban, Tarlac
IBP O. R. # 684881, 01-02-08, Tarlac Chapter
Doc. No. ____;

Page No. ____;
Book No. III;
Series of 2008.
MUNICIPALITY OF CAPAS )
AFFIDAVIT OF LOSS
I, IRENE B. FACUNLA, of legal age, Filipino, single, with residence and

postal address at Brgy. Cut-Cut 1st, Capas, Tarlac, Philippines, after being
sworn to in accordance with law, freely depose and say: THAT
6. On January 25, 2009, about 10:00 11:00 oclock in the morning,

while I was riding a Public Utility Jeepney route Angeles to Mabalacat,
Pampanga I inadvertently loss my Allied Bank ATM Card and all
efforts to locate the same since then up to the present time has been
in vain.
7. I went to the Allied Bank Capas, Tarlac Branch and reported the lost
of my ATM Card and requested the officers thereat to block said Allied
Bank ATM Card and to declare the same as null and void.
8. I am executing this affidavit to attest to the truth of all the foregoing;

to request Allied Bank Capas, Tarlac Branch to declare the lost ATM
Card of mine as null and void; and to issue a new one in my name.
IN WITNESS WHEREOF, I have hereunto affixed my signature this ___

day of January 2009 at Capas, Tarlac, Philippines.
IRENE B. FACUNLA
Affiant
Drivers Licence No. C11-07-007245
SIGNED IN THE PRESENCE OF:
______________________ ______________________
SUBSCRIBED AND SWORN to before me this ____ day of January 2009,

affiant is known to me and to me known to be the same person who executed
the foregoing instrument and acknowledged to me that the same is her free act
and deed and that she voluntarily executed the same and understood all the
contents thereof.

Doc. No. _____;
Page No. _____;
Book No. ____;
Series of 2009.
and to issue a new one in my

name; that I am willing to surrender the lost ATM Card in the event that the same
could be found and located; that I bind myself to hold LANDBANK free and harmless
from any loss and damage that my arise or it may incur in connection with the
issuance of a new ATM Card; that I am willing to testify before any court of justice to
substantiate the truth of each and all of the above said facts;

Affidavit of Loss

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Affidavit of Loss

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REPUBLIC OF THE PHILIPPINES)

PROVINCE OF _________________ : S.S.

I, ARNALDO P. DIZON, of legal age, Filipino, married, with residence and

1. I am the registered owner of the motor vehicle described below as, to

MAKE : Mitsubishi - Fuso

2. As proof of ownership of the above described vehicle, I was issued by

3. Said documents while in my possession were misplaced and could

4. Said documents were not confiscated by any government authorities

5. I shall assume any responsibility or liability if in any event the said

6. I am executing this affidavit to attest to the veracity of my

IN WITNESS WHEREOF, I have hereunto affixed my signature this 24 th

SUBSCRIBED AND SWORN to before me this 24th day of June 2014 at

WITNESS MY HAND AND SEAL.

Doc. No. ______;

I, MARICAR LOPEZ DE GUZMAN, of legal age, Filipino, single, with

1. Sometime on October 09, 2013, I pawned my 3.10 grams 18k Pulcera

2. Consequently, I was issued a Pawn Ticket by said Cebuana Lhuillier

4. I am executing this Affidavit of Loss to attest to the truth of all the

IN WITNESS WHEREOF, I have hereunto affixed my signature this 21 st day

MARICAR LOPEZ DE GUZMAN

SUBSCRIBED AND SWORN to before me this 21 st day of January 2014 at

WITNESS MY HAND AND SEAL.

ATTY. ARNALDO P. DIZON

I, JESSICA D. AMURAO, of legal age, Filipino, single, with residence and

5. I am a registered voter and a holder of a Commission on Election

6. On December 16, 2013, while I was riding a passenger tricycle at

7. Since then, I tried to locate and retrieved my said COMELEC ID but

8. I am executing this Affidavit of Loss to attest to the truth of all the

IN WITNESS WHEREOF, I have hereunto affixed my signature this 14 th

SUBSCRIBED AND SWORN to before me this 14 th day of January 2014

WITNESS MY HAND AND SEAL.

ATTY. ARNALDO P. DIZON

I, GISELLE SIBAL-TAKAHASHI, of legal age, Filipino, with residence and

1. I am the legal and biological mother of minor MIYUKI TAKAHASHI,

2. My daughter MIYUKI is a holder of a Japanese Passport No.

3. Sometime in August 2012, while I and my daughter was in a

4. I am executing this Affidavit of Loss to attest to the truth of all the

IN WITNESS WHEREOF, I have hereunto affixed my signature this ______

SUBSCRIBED AND SWORN to before me this _____ day of January 2013

WITNESS MY HAND AND SEAL.

Doc. No. _____;

I, GAUDENCIO ADLAI A. DIZON, of legal age, Filipino, married to APPLE

1. I am a depositor and holder of a Savings Account Passbook with

2. Sometime in March 2012, while I was about to update my Savings

4. I am executing this Affidavit of Loss to attest to the truth of all the

IN WITNESS WHEREOF, I have hereunto affixed my signature this 30 th

GAUDENCIO ADLAI A. DIZON

SUBSCRIBED AND SWORN to before me this _____ day of August 2012 at

WITNESS MY HAND SEAL.

1. I am a registered member of PhilHealth and a holder of a PhilHealth

2. Sometime in February 2012, while I was at a Supermarket, my

3. Since then, I tried to locate and retrieved my PhilHealth ID but all

4. I am executing this Affidavit of Loss to attest to the truth of all the

IN WITNESS WHEREOF, I have hereunto affixed my signature this 9 th

WILSON SIBAL, Jr.

SUBSCRIBED AND SWORN to before me this _____ day of May 2012 at

WITNESS MY HAND SEAL.

ATTY. ARNALDO P. DIZON

Doc. No. _____;

1. I am the registered owner of the certain motor vehicle, which more

IN WITNESS WHEREOF, I have hereunto affixed my signature this 13 th day of

JULY MOLATO AGUSTIN