REPUBLIC OF THE PHILIPPINES )

QUEZON CITY ) SS.

AFFIDAVIT OF LOSS

I, ROMEO RAMOS DUMAUA, Filipino, of legal age, and a resident of Purok 2

Brgy. Militar, Fort Magsaysay, Nueva Ecija, after having been duly sworn in accordance
with law, hereby depose and say that:

1. That I am the owner/possessor of AMWSLAI Passbook, AMWSLAI ID, Veterans

PVAO ID and ATM Lan Bank;

2. That on July 4, 2018, my clutch bag, containing the above mentioned items, was
inadvertently left inside Jollibee fast-food store in Taguig City, and after few minutes,
upon realizing the same, I returned to the said store to retrieve the same, but the same was
already missing.

4. That despite diligent efforts to locate the same all efforts proved fruitless up to the
present and fear that the same was lost beyond recovery.

4. That I am executing this affidavit to attest to the truth of the foregoing instrument and
for any legal purposes and intent this may serve.

IN WITNESS WHEREOF, I have hereunto affixed my signature this 30th day of

July, 2018 at Quezon City, Philippines.

ROMEO RAMOS DUMAUA

Affiant
ID No. ____________
Issued on _________
Issued at _________

SUBSCRIBED AND SWORN to before me, this 30th day of July 2018 at Quezon
City. Affiant exhibiting to me his/her Identification Document as indicates above.

Doc No.______
Page No._____ NOTARY PUBLIC
Book No._____
Series of 2018.