REPUBLIC OF THE PHILIPPINES )

PROVINCE OF AGUSAN DEL NORTE )

CITY OF CABADBARAN ) S.S.
X--------------------------------------------)
  
AFFIDAVIT OF LOSS
I, RUTH S. LUMAG, of legal age, Filipino, married, and a resident of
Brgy. 11, Aglipay St., Cabadbaran City, Agusan del Norte, Philippines, after
having been sworn in accordance with law, hereby depose and state the
following:

1. My late son RENZ HARRY S. LUMAG is the

holder/owner/possessor of the following identification card/document:
Fortune Life Policy Contract under unknown account number;

2. Sometime on the month of August 2019, the contract was misplaced

in my house;

3. Despite diligent efforts exerted, I could no longer locate, find or

recover the  said contract, and to the best of my knowledge, the same
is truly lost and

3. I execute this affidavit to attest to the truth of the foregoing.

IN WITNESS WHEREOF, I have hereunto set my hand this April 6,

2021 in Cabadbaran City, Agusan del Norte, Philippines.

Signed:

RUTH S. LUMAG
Affiant

SUBSCRIBED AND SWORN TO before me in Cabadbaran City,

Agusan del Norte, Philippines this April 6, 2021 affiant who exhibited to me her
Pag-IBIG ID: 1830-0061-6568.

Doc. No. 240

Page No. 49
Book No. XXXVIII
Series of 2021