Republic of the Philippines}

City of Dipolog……..……….}s.s.

AFFIDAVIT OF LOSS

I, NENITA E. CASIPLE, Filipino, of legal age, widow and a resident of

Purok-1, Brgy. Poblacion, Sibutad, Zamboanga del Norte, after having been duly
sworn to in accordance with law, do hereby depose and say, That:

1. I am the custodian and holder of the AFPSLAI Passbook with No. ______________
of my late husband as well as his AFPSLAI Identification (ID) Card with No.
__________________;

2. Sometime in January 2020, I discovered that the said Passbook and ID were
missing;

3. Despite diligent search and efforts to locate the said Passbook and ID, I could not
find the same;

4. I have not assigned nor encumbered the afore-said Passbook and ID; and

5. I am executing this affidavit to attest to the truth of the foregoing circumstances

and for all legal purpose and intent it may serve.

IN WITNESS WHEREOF, I have hereunto affixed my signature this

_________________ at Dipolog City, Philippines.

NENITA E. CASIPLE
Affiant
Senior Citizen ID No. SIB-15-1516

SUBSCRIBED AND SWORN to before me this ____________________ at

Dipolog City, Philippines, by affiant who exhibited to me a valid proof of her
identity who personally signed the foregoing instrument before me and avowed
under penalty of law to the whole truth of the contents of said instrument.

Doc No.: _____;

Page No.: _____;
Book No.: _____;
Series of 2020.