REPUBLIC OF THE PHILIPPINES)

Province of Cagayan ) S.S.

City/Municipality of Tuguegarao )
x-----------------------x

AFFIDAVIT OF LOSS
I, YULO VINCENT B. PANUNCIO, JR, Filipino, of legal age, single, and
a resident of No. 117 Provincial Road Cataggaman Nuevo Tuguegarao City,
Cagayan, Philippines, after being duly sworn to in accordance with law,
hereby depose and state:

1. That I am an employee of Cagayan Valley Medical Center at Carig

Sur, Tuguegarao City, Philippines and at the same time a duly-
licensed driver;

2. That on July 22, 2017 at around 10:00 pm, while I was at the Jolibee
Tanza Tuguegarao City, I lost my wallet which I usually place inside
my pocket;

3. That inside the said wallet are my School ID’s and ATM Card issued
by Land Bank of the Philippines, Carig Branch;

4. That despite diligent search and efforts to locate the said wallet and
School ID’s and my ATM Card, I could not find them such that I now
believe that they are now lost beyond recovery;

5. As such, I am executing this Affidavit of Loss to attest to the truth of

the foregoing and to support my application for the issuance of my
GSIS ECard.

IN WITNESS WHEREOF, I have hereunto set my hand this 18 th Day of

May at Tuguegarao City, Cagayan, Philippines.

YULO VINCENT B. PANUNCIO, JR.

AFFIANT

SUBSCRIBED AND SWORN to before me, this _____________, by the Affiant who is
personally known to me (or whom I have identified through competent evidence of identity) and
who exhibited his/her Community Tax Certificate No. _____________ issued at _____________ on
_____________. or Identification Card No. ____ issued by ______ with expiry on ________.

NOTARY PUBLIC

Doc. No. ______;

Page No. ______;
Book No.______;
Series of _______.