Republic of the Philippines)

City of )S.c.

AFFIDAVIT OF LOSS

I, ________________, representing my late ____________, _________________,

of legal age, Filipino, married and a resident of ____________________, after having
been duly sworn in accordance with law, do hereby depose and say:

1. That my late brother, ______________, who died on ___________,

was a holder of a St. Peter Life Plan with LPA no. _______________
issued to him as a member thereof;
2. That unfortunately, when I was looking for said Policy or Life plan and
his St. Peter Life Plan plan-holder’s identification card inside in his
house or anywhere in my late brother’s belongings, I could no longer
find it;

3. That due efforts has been made in order to retrieve said Policy or LPA
and St. Peter Life Plan plan-holder’s identification card but to no avail,
thus, I am considering it lost forever;

4. That I am executing this affidavit to attest to the foregoing facts and for
any legal purpose this may serve.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ____ day of

_____________ at ____________, Philippines.

_________________
Affiant

SUBSCRIBED AND SWORN to before me this ____ day of ______________ at

Sorsogon City, Philippines, affiant having presented to me his/her _________ with ID no.
__________________.

Doc. no.
Page no.
Book no.
Series of 2021