Republic of the Philippines)

Province of Southern Leyte)s,s

CITY OF MAASI)
!""""""""""""""""""""""""""""""!
AFFIDAVIT OF LOSS
I, MERLINA MONTEGERMOSO BACLAAN, of le#$l $#e, %$rrie&,
Filipino $n& $ resi&ent of Concepcion, M$litobo#, Southern Leyte, $fter h$vin#
been &uly s'orn to in $ccor&$nce 'ith l$', &o hereby &epose $n& s$y(
)* Th$t I $% the hol&er $n& possessor of $ SSS Card, issue& by SSS
M$$sin +r$nch,
-* Th$t unfortun$tely, the s$i& SSS C$r& '$s lost in the usu$l pl$ce
'here I .ept it* I l$unche& $n i%%e&i$te se$rch in or&er to /n& it but the
s$%e prove& futile* I no' consi&ere& the s$i& SSS C$r& irretriev$bly
lost $n& beyon& recovery, 'ithout the f$ult in %y p$rt,
0* Th$t I e!ecute& this A1&$vit in or&er to $1r% $n& con/r% the
fore#oin# f$cts $n& for $ll other le#$l intents $n& purposes this %$y serve*
I 2IT3SS 243R3OF, I h$ve hereunto set %y h$n& this 555555555555
$t M$$sin City, Southern Leyte*
MERLINA MONTEGERMOSO BACLAAN
A1$nt
SUBSCRIBED AND SWORN TO +3FOR3 M3, this )6
th
&$y of
Septe%ber -6)7 $t M$$sin City, Southern Leyte*
8oc o( 5555,
P$#e o( 5555,
+oo. o( L999:I
Series of( -6)7
Republic of the Philippines)
Province of Southern Leyte)s,s
CITY OF MAASI)
!""""""""""""""""""""""""""""""!
AFFIDAVIT OF LOSS
I, JERRY R. BENDIJO, of le#$l $#e, Filipino $n& $ resi&ent of
Co%b$&o, M$$sin City, Southern Leyte, $fter h$vin# been &uly s'orn to in
$ccor&$nce 'ith l$', &o hereby &epose $n& s$y(
)* Th$t I $% the hol&er $n& possessor of $n ATM CARD un&er
SA o* 6)7"0;"60-;<"7 &uly issue& by =R33+A>,
-* Th$t unfortun$tely, the s$i& ATM CAR8 '$s lost in the usu$l pl$ce
'here I .ept it* I l$unche& $n i%%e&i$te se$rch in or&er to /n& it but the
s$%e prove& futile* I no' consi&ere& the s$i& ATM CAR8 irretriev$bly
lost $n& beyon& recovery, 'ithout the f$ult in %y p$rt,
0* Th$t I e!ecute& this A1&$vit in or&er to $1r% $n& con/r% the
fore#oin# f$cts $n& for $ll other le#$l intents $n& purposes this %$y serve*
I 2IT3SS 243R3OF, I h$ve hereunto set %y h$n& this 555555555555
$t M$$sin City, Southern Leyte*
JERRY R. BENDIJO
A1$nt
SUBSCRIBED AND SWORN TO +3FOR3 M3, this 5555555555555555 $t
M$$sin City, Southern Leyte*
8oc o( 5555,
P$#e o( 5555,
+oo. o( L999:I
Series of( -6)7