REPUBLIC OF THE PHILIPPINES}

PROVINCE OF BENGUET } SS.

---------------------------------------------

AFFIDAVIT OF LOSS

I. LORENDIA DANGATAN, of legal age, married, Filipino citizen and presently

residing at A-114, Housing, Publacion, La Trinidad, Benguet, after having been sworn to in
accordance with law, hereby depose and state that:

1. In the morning of September 20, 2009, I went to Vegetable parking at Pico, Km.5, La
Trinidad, Benguet, carrying with me my purse containing my SMART MONEY
CARD, PHILHEALTH IDENTIFICATION CARD, TIN CARD, PRC CARD, TWO
CELL PHONES (containing Sim Cards nos. 09298160559 and 09127513793
respectively), THREE CHECKS (one in the name of Allied Bank and two checks in
the name of China Bank), and an ATM CARS with account number. 2980052215,
issued by the China Bank located at Km.4, La Trinidad, Benguet;

2. The said purse however was lost while I was busy repacking vegetables along the
Vegetable parking, Located at Pico, La Trinidad, Benguet;

3. I took pains and exerted all diligent efforts to look for my lost purse but to no avail:

4. Considering that the lost is beyond recovery, I am executing these statements to

request the Phil. Health Office, Professional Regulatory Commission, Bureau of
Internal Revenue and China Bank to grant me new Identification card, Tax
Identification card and new ATM card respectively;

5. I am Executing these statements to request the SMART CORPORATION located at

SM Baguio, to grant me new U-2 Sim Card;

6. I am executing this affidavit to attest to the truth of all the foregoing statements and
as well as for all legal intents and purposes this may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this 21st day of September,
2009 at La Trinidad, Benguet, Philippines.

LORENDIA DANGATAN
Affiant

SUBSCRIBED AND SWORN TO BEFORE ME, this 21st day of September, 2009 at
La Trinidad, Benguet, Philippines, by LORENDIA DANGATAN who has satisfactorily proven
to me her identity through, CYNTHIA M. SOLIGAM, who is personally known to me and who
personally knows the principal, that he is the same person who executed the foregoing affidavit
before me and acknowledged that She executed the same.

ATTY. JAKE AWAL SAGPAEY

Notary Public
Until December 2011
 IBP NO. 7887704/ BAGUIO-BENGUET/ 04-21-09
PTR NO.6564808/BENGUET/05-27-09
ROLL NO. 57226

DOC NO.
PAGE NO.
BOOK NO.
SERIES OF 2009

OATH OR AFFIRMATION OF THE WITNESS

I, CYNTHIA M. SOLIGAM , of legal age, Filipino, married, and presently residing at

N0. A-114, Housing, Publacion, La Trinidad, Benguety, hereby affirmed under the penalty of
law that the foregoing statements are true:

1. That LORENDIA DANGATAN , the affiant principal, is the same person named in
the instrument;

2. That LORENDIA DANGATAN is personally known to the undersigned witness to

be the same person who executed and signed the foregoing affidavit;

3. That J LORENDIA DANGATAN does not possess a current identification document

as required by the rules as her bag containing her Identification Documents was
stolen last September 20, 2009;

4. That the undersigned witness is not a privy to the instrument;

5. That the undersigned witness has presented his valid identification Card No. C-215
issued by the Department of Agriculture.

IN WITNESS WHEREOF, I hereby affixed my signature, this 21st day of June in the
Municipality of La Trinidad, Benguet, Philippines.

CYNTHIA M. SOLIGAM
Affiant

CERTIFICATION

I hereby certify that I examined CYNTHIA M. SOLIGAM , a Filipino citizen, of legal

age, single, and presently residing at N0 A-114, Housing, Publacion, La Trinidad, Benguet,,
Philippines, and she avowed under the penalty of law to the whole truth of the oath.

ATTY. JAKE AWAL SAGPAEY

Notary Public
Until December 2011
IBP NO. 7887704/ BAGUIO-BENGUET/ 04-21-09
PTR NO.6564808/BENGUET/05-27-09
ROLL NO. 57226
 SUBSCRIBED AND SWORN TO BEFORE ME, this 21st day of September, 2009 at
La Trinidad, Benguet, Philippines, by CYNTHIA M. SOLIGAM , personally known to me, who
is the same person who personally appeared and signed before me the foregoing affirmation and
acknowledged that she voluntarily executed the same.

ATTY. JAKE AWAL SAGPAEY

Notary Public
Until December 2011
IBP NO. 7887704/ BAGUIO-BENGUET/ 04-21-09
PTR NO.6564808/BENGUET/05-27-09
ROLL NO. 57226

DOC NO.
PAGE NO.
BOOK NO.
SERIES OF 2009