REPUBLIC OF THE PHILIPPINES )

SAN NICOLAS, ILOCOS NORTE ) S.S

AFFIDAVIT OF LOSS

I, WILMA M. VALENZUELA, of legal age, Filipino, and a resident of Brgy.

2, Primo Lazaro St., Laoag City, Ilocos Norte, Philippines, after having been
duly sworn to in accordance with law, hereby depose and states that:

1. I was issued a Certificate of Full Payment by Cooperative Insurance

System of the Philippines;

2. Vitally, commencing from its issuance, I always safekept said

certificate inside a small steel cabinet located in the living room of our
house;

3. Relatively, just recently, or sometime in January 2024, I noticed that

the said certificate was no longer inside the said steel cabinet where I
last and usually kept it;

4. I immediately exerted diligent efforts to search for the whereabouts of

the said certificate. Regrettably, all of my efforts turned futile. Hence, I
now consider the said certificate lost and beyond recovery;

5. The said certificate was neither confiscated nor seized for any
violation of law, rules and regulation;

6. I am executing this affidavit to request the authorities concerned to

issue me a new certificate in lieu of the lost one; and

7. That I am executing this affidavit to attest to the veracity of my

statements and for whatever intents and purposes it may lawfully
serve.

IN WITNESS WHEREOF, I have hereunto set our hands this 13 th day of

March 2024 at San Nicolas, Ilocos Norte, Philippines.

WILMA M. VALENZUELA
Affiant
ID NO.__________________

SUBSCRIBED AND SWORN to before me this 13th day of March 2024 at

San Nicolas, Ilocos Norte, Philippines.

Doc. No. 129;

Page No. 27;
Book No. CCXXXVII;
Series of 2024.