Republic of the Philippines) S.

AFFIDAVIT OF LOSS

I, JANSEN DELA CRUZ, Filipino, single, of legal age, RESIDENT OF _______

Pampanga, after being duly sworn in accordance with law, depose and state that:

1. I am the owner of (a) a Banco De Oro (BDO) Automated Teller Machine (ATM) Card-
with Card number: and (b) a Professional Regulations Commission (PRC) ID
(Electronics Technician) with License No. , which I usually keep in my wallet.

2. On January 31, 2019, while I was walking somewhere in Pampanga, I realized that my
wallet which I kept in my back pocket was missing and the said BDO ATM Card and
PRC License ID were also lost. Their whereabouts cannot be ascertained despite due and
diligent search made and undertaken such that I now believe that the same is lost beyond
recovery;

3. That for legal intents and purposes, the same is deemed lost.

4. As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing and
for whatever legal purpose that this may serve.

AFFIANT FURTHER SAYETH NAUGHT.

IN WITNESS WHEREOF, I have hereunto set my hands this ___ day of March 2019 at
_______________, Philippines.

JANSEN R. DELA PEÑA

Affiant

SUBSCRIBED AND SWORN to before me this _______ at Mabalacat City, Pampanga,

Philippines, affiant exhibited to me his Passport _________________ issued on __________
valid until _____________.

Doc. No. ____,

Page No. ____,
Book No. ____,
Series of 2019.