REPUBLIC OF THE PHILIPPINES)

PROVINCE OF SAMAR) S.S.

CITY/MUNICIPALITY OF____________________

AFFIDAVIT OF LOSS

I, Ms. STEPHANIE M. SURRIGA, Filipino, of legal age and a resident of DEL

ROSARIO STREET, BARANGAY POBLACION 4, SAN SEBASTIAN, SAMAR ,
after being sworn to in accordance with the law, do hereby depose and say:

1. That I am the owner of PRC PROFESSIONAL IDENTIFICATION CARD.

2. That on or about 20 September 2019, I discovered the loss of the said document
under the following circumstance(s);

I presented my PRC ID during the official transaction at Land Bank of the

Philippines Catbalogan Branch to verify my identity but the same was lost
and notwithstanding diligent efforts, the same cannot be recovered or located
and I believe that it is truly lost.

3. That I am executing this affidavit to attest the truth and for whatever legal purpose
it may serve.

_____________________________
STEPHANIE M. SURRIGA
Affiant

SUBSCRIBED AND SWORN to before me this _____ day of ______, 2019 in -

_______________, Samar

Doc. No.______;
Page No.______;
Book No.______;
Series No. _____.