REPUBLIC OF THE PHILIPPINES)

MUNICIPALITY OF ___________ ) S.S.

AFFIDAVIT OF LOSS

I, POLO R. TECSON of legal age, Filipino, single and a resident of Daro,

Dumaguete City after having been sworn in accordance with law, depose and say
that:

1. I am holder of one (1) SPI Identification card and one (1) Kronos
Timestamp card;

2. On August 10, 2019 my above-mentioned items became lost, possibly

falling out of my pockets while I was riding my bicycle from my place of
employment headed towards my residence;

3. Despite diligent attempts to locate, recover and retrieve said SPI ID and
Kronos Timestamp Card, they could no longer be found, such that I believe that it is
now lost and beyond recovery;

4. The said SPI ID and timestamp card have not been encumbered, sold,
pledged, assigned, alienated, transferred, donated or given as collateral for any debt
or obligation to or in favor of any person or entity;

5. I am executing this affidavit to establish the circumstances surrounding

the loss of my above-mentioned items, the issuance of a new ones and for whatever
legal purpose;

6. This affidavit is executed to attest to the truthfulness and veracity of my

statements above.

IN WITNESS WHEREOF, I have hereunto affixed my signature this

______________ at Dumaguete, Negros Oriental, Philippines.

POLO R. TECSON
Affiant

SUBSCRIBED AND SWORN to before me _____________, at Bacong,

Negros Oriental. Showing to me as proof of identity his Police Clearance No.
C2471745 issued on March 13, 2019

Doc. No.: ___

Page No.: ___
Book No.: ___
Series of 2019.