REPUBLIC OF THE PHILIPPINES )

City of_________________________ )

AFFIDAVIT OF LOSS

I, EDITHA A. ROGEL, Filipino, married, of legal age, and a resident of

Purok Ilang-ilang Atimonan, Quezon Province, Filipino, of legal age, after
having been sworn to in accordance with law, hereby deposes and states that:

1. On 05 June 2022, at around 11: 30am o’clock in the afternoon,

I noticed that my wallet was missing when I checked my pocket in my desk.

2. Earnest efforts to locate the said wallet proved futile. I

believe that the said wallet may have been lost while I was on my store of Three
Borther’s Ukay-ukay Atimonan, Quezon;

3. Among those that were included in the lost wallet are my

identification and membership cards with the following:

- Voter’s ID
- Vaccine Card
- Card ID Inc.,
- Cash amount Php 34, 000.00

4. I am executing this Affidavit to attest to the truth of the

foregoing statements and for whatever legal purpose this may serve.

AFFIANT FUTHER SAYETH NAUGHT.

IN WITNESS WHEREOF, I hereunto set my hands this ___ day of ______,

2022 at ___________.

EDITHA A. ROGEL
Affiant

SUBSCRIBED AND SWORN TO before me this ___day of _________, 2021 in

_____________ City, affiant exhibiting to me her Police Clerance 0199300 as proof
of her competent evidence of identity, and I hereby certify that I personally
examined the affiant herein and that I am fully satisfied that she voluntarily
executed this affidavit.

Doc. No. ________;

Page No. ________;
Book No. _______;
Series of 2022.