Republic of the Philippines…}

Province of Surigao del Sur…}

City of Tandag…} S. S.

AFFIDAVIT OF LOSS

I, CORPUS P. FERNANDEZ, JR., Filipino, of legal age and a resident of Mabua,

Tandag City, Surigao del Sur, state under oath, THAT:

1. I am a holder of GSIS ID, with Policy # CM00005203307 and

BP#2000498918;

2. I kept said GSIS ID in my wallet which contains also other important

documents;

3. However, the wallet which contains the said GSIS Identification Card and other
important documents was lost;

4. I exerted all efforts to locate the same but to no avail;

5. I am executing this Affidavit to apprise GOVERNMENT SERVICE

INSURANCE SYSTEM (GSIS) the fact of said loss and for whatever legal purpose this
may serve best.

IN WITNESS WHEREOF, I have hereunto set my hand this 27th day of June
2014, in Tandag City, Surigao del Sur, Philippines.

CORPUS P. FERNANDEZ, JR.

Affiant

SUBSCRIBED AND SWORN TO BEFORE ME, a Notary Public for and in the
Province of Surigao del Sur, this 27th day of June 2014, in Tandag City, Surigao del
Sur, the affiant personally appeared and affixed his signature together with his ID as
proof of his identity.

ANDREI ARREZA ANDRESAN

Notary Public
IBP No. 811317/ Jan.8, 2014; Surigao del Sur
PTR No. 4936048/ Jan.6, 2014; Surigao del Sur
IBP Roll No. 41883
MCLE Compliance No. IV- 0013490
Misc. Case No. 05-2014
 Doc. No. 07 ; Page No. 02 ; Book No. XVII ; Series of 2014.

Republic of the Philippines…}

Province of Surigao del Sur…}
City of Tandag…} S. S.

AFFIDAVIT OF LOSS

I, VIZMINDA B. LAGURA, Filipino, of legal age, married, and a resident of Brgy.

Telaje, Tandag City, Surigao del Sur, state under oath, THAT:

1. I am a holder of GSIS CARD with Policy # CM-4520801/B68LHV8039;

2. I kept said GSIS Card in my wallet which contains also other important
documents;

3. However, the wallet which contains the said GSIS Card and other important
documents was lost;

4. I exerted all efforts to locate the same but to no avail;

5. I am executing this Affidavit to apprise GSIS the fact of said loss and for
whatever legal purpose this may serve best.

IN WITNESS WHEREOF, I have hereunto set my hand this 2 ND day of June

2014, in Tandag City, Surigao del Sur, Philippines.

VIZMINDA B. LAGURA
Affiant

SUBSCRIBED AND SWORN TO BEFORE ME, a Notary Public for and in the
Province of Surigao del Sur, this 2 ND day of June 2014, in Tandag City, Surigao del Sur,
the affiant personally appeared and affixed her signature together with her ID as proof
of her identity.

ANDREI ARREZA ANDRESAN

Notary Public
IBP No. 811317/ Jan.8, 2014; Surigao del Sur
PTR No. 4936048/ Jan.6, 2014; Surigao del Sur
IBP Roll No. 41883
MCLE Compliance No. IV- 0013490
 Doc. No. 05 ; Page No. 01 ; Book No. XVII ; Series of 2014.

Republic of the Philippines…}

Province of Surigao del Sur…}
City of Tandag…} S. S.

AFFIDAVIT OF LOSS

I, JENNO R. BEÑALES,Filipino, of legal age, married, and a resident of Brgy.

Awasian, Tandag City, Surigao del Sur, state under oath, THAT:

1. I am a holder of Tax Identification Card with TIN number 937-608-010;

2. I kept said Tax Identification Card in my wallet which contains also other
important documents;

3. However, the wallet which contains the said Tax Identification Card and other
important documents was lost;

4. I exerted all efforts to locate the same but to no avail;

5. I am executing this Affidavit to apprise BUREAU OF INTERNAL REVENUE

(BIR) the fact of said loss and for whatever legal purpose this may serve best.

IN WITNESS WHEREOF, I have hereunto set my hand this 30 th day of January

2014, in Tandag City, Surigao del Sur, Philippines.

JENNO R. BEÑALES
Affiant

SUBSCRIBED AND SWORN TO BEFORE ME, a Notary Public for and in the
Province of Surigao del Sur, this 30 th day of January 2014, in Tandag City, Surigao del
Sur, the affiant personally appeared and affixed her signature together with her ID as
proof of her identity.

ANDREI ARREZA ANDRESAN

Notary Public
IBP No. 811317/ Jan.8, 2014; Surigao del Sur
PTR No. 4936048/ Jan.6, 2014; Surigao del Sur
IBP Roll No. 41883
MCLE Compliance No. IV- 0013490
Doc. No. _______; Page No. _________; Book No. __________; Series of 2014.