REPUBLIC OF THE PHILIPPINES)

Santa Rosa City, Laguna ) SS.

AFFIDAVIT OF LOSS

KNOW ALL MEN BY THESE PRESENTS:

I, ISABELO G. SALAO and of legal age and residing/with address at Brgy. Bilaran, Nasugbu,
Batangas, under oath, state:

1. THAT on 17 DECEMBER 2021 while on a motorcycle on our way from Nasugbu, Batangas
to our place of work in Santa Rosa City, Laguna my wallet got lost;

2. THAT my wallet contained, along with some money bills, my Security Bank ATM Card for
Savings Account Number 0000027531866, Loyalty Card Plus with Card No. 1211-1851-2815, as well as
that of Ms. NICETA ALCANTARA, Security Bank ATM Card for Savings Account Number
0000026240160 and Loyalty Card Plus with Card No. 1211-3301-2905 ;

3. THAT I exerted diligent efforts to locate my wallet but to no avail and I therefore considered
the same as lost and can no longer be found;

4. THAT I am executing this Affidavit to attest to the truth of the foregoing facts and to use the
same for whatever legal purpose it may serve.

IN WITNESS WHEREOF, I hereunto affix my signature this ____ day of December 2021 at Santa
Rosa City, Laguna.

ISABELO G. SALAO
Affiant

SUBSCRIBED and SWORN TO before me on the date and at the place indicated below. The affiant
exhibited to me his TIN ID with ID No. 435-220-093.

Signed this ____ day of December 2021 at Santa Rosa City, Laguna, Philippines.

WITNESS MY HAND AND SEAL.

Notary Public

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