REPUBLIC OF THE PHILIPPINES)

CITY OF MALOLOS) S.S.

AFFIDAVIT OF LOSS

I, Sharmaine Marie G. Raymundo. of legal age, single, currently residing at #172 BE

Mabini St., Barihan, Malolos City, Bulacan, after being sworn to in accordance with law, hereby
depose and state:
That sometime on April 30, 2015, I applied for correction of my surname, middle name
and my fathers name at the Local Civil Registry Office at the Plaridel Municipal Office, Plaridel,
Bulacan and for which I was issued a claim stub/receipt;

That on May 11, 2015 at around 7:00 o clock in the evening, while I was at the Malolos
Public Market, City of Malolos, Bulacan, I lost my bag which I usually carry with me;
That inside the said bag was the claim stub/receipt issued by the Local Civil Registry
Office of Plaridel, Bulacan and other pertinent documents;
That despite diligent search and efforts to locate the said bag and the claim stub/receipt,
I could not find them such that I now believe that they are now lost beyond recovery;
As such, I am executing this affidavit to attest to the foregoing facts and to enable me to
secure a duplicate or substitute copy of the claim stub/receipt and/or redeem the corrected copy
of my surname, middle name and my fathers name from the Local Civil Registry of Plaridel;
IN WITNESS WHEREOF, I have hereunto set my hand this 28th of July, 2015 in Malolos
City, Bulacan, Philippines.
Sharmaine Marie G. Raymundo
Affiant

SUBCRIBED AND SWORN TO before me this ________________in

_________________, Philippines, affiant exhibiting to me his competent evidence of
identification.

Doc. No. _____;

Page No. _____;

Book No. _____;

Series of 2015.