Republic of the Philippines)

Dumaguete City ) S.S.

AFFIDAVIT OF LOSS

I, DIOGULLY KADUSALE, of legal age, Filipino, married, with residence and

postal address at Looc, Dumaguete City, Negros Oriental, Philippines, after
having been duly sworn to in accordance with law, hereby depose and state:

1. That I am a holder of the following Identification Cards (ID), namely:

a. PhilHealth ID
b. ACEA Engineering Services Co. ID (employment ID);

2. That I used to put these IDs in my wallet;

3. That sometime in Dec. 25, 2018, my wallet was lost together with the
aforementioned IDs inside and my money in the amount of Four Thousand
Seven Hundred Pesos (PhP4,700.00);

4. That efforts were exerted to locate the said wallet, but in spite of diligent
search, it could not be found and the same is now beyond my recovery;

5. That I am executing this affidavit to attest to the truth of the foregoing facts
and for whatever legal purpose it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this _____________________,

at Dumaguete City, Philippines.

DIOGULLY KADUSALE
Affiant

SUBSCRIBED AND SWORN TO before me this ____________________ in

Dumaguete City, Philippines, affiant exhibiting to me his valid proof of
identification.

Doc. No. ____;

Page No. ____;
Book No. ____;
Series of 2019.