REPUBLIC OF THE PHILIPPINES)

PROVINCE OF SAMAR…………...) S.S.

CITY OF CATBALOGAN………….)

AFFIDAVIT OF LOSS

I, MARIA ATHENELYN D. GONZAGA, of legal age, married,

Filipino and a resident of Purok 2, Brgy. Canlapwas, Catbalogan City,
Samar, after having been duly sworn to in accordance with law, do hereby
depose and state: that-

1. I am an employee of Samar II Electric Cooperative, Inc.

(SAMELCO II) Paranas, Samar; as such, I am maintaining a
savings deposit with the China Banking Corporation, Catbalogan
Branch, Catbalogan City with corresponding passbook issued in
my favor;

2. Unfortunately, however, on 18 October 2015, the SAMELCO II

main building was gutted by fire, including the instruments and
fixtures therein contained, and specifically the said passbook; and
despite earnest search and save of said documents, the same
proved futile;

3. The loss of said PASSBOOK is made in good faith and never

intended to defraud the government, particularly, the Chinabank,
and third persons and I hold the said agencies free from any
liabilities or obligations arising from such loss;;

4. I am executing this affidavit to attest the truth of all the foregoing

and for other legal purposes.

IN WITNESS WHEREOF, I have hereunto affix my signature this 27 th

day of April 2022 at Catbalogan City.

MARIA ATHENELYN D. GONZAGA

Affiant

SUBSCRIBED AND SWORN to before me this 27 th day of April 2022

at Catbalogan City, affiant exhibiting to me her SAMELCO II Employee ID
No. 011.

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 2022.
REPUBLIC OF THE PHILIPPINES)
PROVINCE OF SAMAR…………...) S.S.
CITY OF CATBALOGAN………….)

AFFIDAVIT OF LOSS

I, INDIRA L. PALOMO, of legal age, married, Filipino, and with

residence at Brgy. Munoz, Catbalogan City, after having been duly sworn to in
accordance with law, do hereby depose and state: that-

1. I am a holder of a Loyola Life Plan Insurance Policy with

corresponding Certificate of Full Payment issued by the Loyola
Plans Consolidated, Inc., LPI Bldg., 849 A. Arnaiz Avenue,
Makati City;

2. Being an employee of Samar II Electric Cooperative (SAMELCO

II), Brgy. Arado, Paranas, Samar, I had said documents kept in
one of its lockers located at its main building;

3. However, on 18 October 2015, the SAMELCO II main building

was gutted by fire, including the instruments and fixtures therein
contained, and specifically the said policy and certificate; and
despite earnest search of said documents, the same proved
futile;

4. The loss of said documents is made in good faith and never

intended to defraud the Loyola Plans Consolidated, Inc., its
officers and agents, and I hold the same free from any liabilities
or obligations arising from such loss;

5. I am executing this affidavit to attest the truth of all the foregoing

and for other legal purposes.

IN WITNESS WHEREOF, I have hereunto affix my signature this 27 th

day of April 2022 at Catbalogan City.

MARIA ATHENELYN D. GONZAGA

Affiant

SUBSCRIBED AND SWORN to before me this 27 th day of April 2022

at Catbalogan City.

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 2022.