REPUBLIC OF THE PHILIPPINES)

CITY OF ORMOC ) S.S.

AFFIDAVIT OF LOSS
(RE: Quarantine Pass)

I, MIKE L. LUMANTA, of legal age, Filipino, single and a resident of Barangay Doña Feliza Mejia
Subdivision, Ormoc City, Leyte, Philippines, after having been duly sworn to in accordance with law do hereby
depose and say that;

1. I am bonafide resident of Barangay Barangay Doña Feliza Mejia Subdivision, Ormoc City,
Leyte, Philippines since 2014 until present;

2. The Barangay Doña Feliza Mejia Subdivision, Ormoc City, Leyte, Philippines issued me a
corresponding Quarantine Pass under control number 111-04-0001 as worldwide suffering
this pandemic and battling the unforeseen enemy which is covid-19;

3. The said Barangay issued me a quarantine pass in order to buy for our basic commodities;

4. The said quarantine pass was lost sometime on May 10, 2020;

5. Despite diligent search and efforts to locate the above mentioned quarantine pass I could not
find the same, such that I now believe that it is now lost beyond recovery;

6. As in such, I am executing this Affidavit of Loss in order to attest the facts of loss and for
whatever legal purpose this serves best.

IN WITNESS WHEREOF, I have hereunto affixed my signature this __ day of ______ in Ormoc City,
Philippines.

MIKE L. LUMANTA
Affiant
DL-H03-19-006527

SUBSCRIBED AND SWORN TO before me this __ day of ______ in Ormoc City, Philippines.