REPUBLIC OF THE PHILPPINES )

CITY OF GENERAL S A N T O S) S.S.

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AFFIDAVIT OF LOSS

I, CONCHITA M. VICENTE, of legal age, Filipino, married with postal address at

Tango, Glan, Sarangani Province, after having been duly sworn to in accordance with law, do
hereby depose and say:

1. That on November 20, 2015, I left my pouch at Mama Luisa, General Santos
City;

2. That my pouch contains the following important documents, to wit:

a) Voter’s ID
b) 4 P’s ID
c) CASH

3. That I exerted diligent efforts to locate my bag but the same proved futile;

4. That I am executing this affidavit to attest to the truth of the foregoing facts and
for whatever purpose this may legally serve.

IN WITNESS WHEREOF, I have hereunto set my hand this ___________________

at General Santos City.

CONCHITA M. VICENTE
Affiant

SUBSCRIBED AND SWORN to before me this _______________________ at

General Santos City, Philippines.

Doc. No. ____________;

Page No. ____________;
Book No. ____________;
Series of 2015.