Republic of the Philippines)

La Trinidad, Benguet) s.s

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AFFIDAVIT OF LOSS

I, WILLIAM BRENT M. DAGIW-A, of legal age, married, Filipino, and a resident of

No. JC 004, KM.4, Central Pico, La Trinidad, Benguet after having been duly sworn to in
accordance with law, do hereby depose and state THAT:

1. I am a St. Peter Life Plan Member, with Contract No. R09649746E. As such, I had
been paying my installment payments, the latest of which was on March 21, 2014, as
evidenced by Official Receipt No. 031049, and with a duly issued Certificate of Full
Payment;

2. The said Certificate of Full Payment has been kept by the St. Peter Life Plan
Employee/collector. As such said Certificate has not been issued nor receive by me
since then;

3. Sometime about the last week of November 2021, when I go back to St. Peter Life
Plan Office at Km. 5, La Trinidad, Benguet, purposely to get my return of investment
(investment) I was informed that the said Certificate of Full Payment is needed in
order to get my investment. However, said COFP cannot be located nor the same is
still missing. I strongly believed that the said Certificate of Full Payment has been
inadvertently misplaced or lost without any malice or negligence on my part
whatsoever;

4. Despite all of these earnest efforts, I cannot locate the same. I therefore considered it
lost and beyond recovery;

5. I am executing this Affidavit to request St. Peter Life Plan Incorporated to issue me a
new Certificate of Full Payment (COFP) in lieu of the one which was lost;

6. Finally, I am executing this affidavit to attest to the truthfulness of the foregoing facts
and for all legal intents and purposes it may serve well.

IN WITNESS WHEREOF, I have hereunto set my hand this 16 th day of December 2021
at La Trinidad, Benguet, Philippines.

WILLIAM BRENT M. DAGIW-A

Affiant
TIN: 113-557-215

SUBSCRIBED AND SWORN to before me a Notary Public for and in La Trinidad,

Benguet, Philippines this 16th day of December 2021 by the above Affiant exhibiting to me his
valid ID and identified by to be the same person who personally signed before me the foregoing
Affidavit.

ATTY. CYRUS C. CALAYA

Doc. No. 199; Notary Public until Dec. 31, 2021
Page No. 41; PTR No. BGTCF6233420; Jan. 4, 2021
Book No. IV; IBP Lifetime No. 08051, at Pasig City
Series of 2021. Roll No. 52590, May 12, 2006; Manila
S & B Bldg., FA 224, Km. 4
National, Highway La Trinidad, Benguet