REPUBLIC OF THE PHILIPPINES)

CITY OF GENERAL SANTOS ) S.S.

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AFFIDAVIT OF LOSS

I, AUGUSTINA JESSA R. ALBERCA, of legal age, Filipino, single, resident of Purok

Bulaong Extension, Brgy. Labangal, General Santos City, after having been duly sworn
to in accordance with law, depose and state, THAT:

1. I have a green wallet which contains the following:

 Unified Multi-Purpose ID (UMID) issued from Social Security System of

General Santos City

 Tax Identification Number (TIN) Card issued from Bureau of Internal

Revenue - General Santos City;

 PhilHealth ID Card issued from PhilHealth of General Santos City

 Voter’s ID issued from Commission on Election of General Santos City

 Penbank Passbook with Account Number 31-100-38337-20 issued

Penbank of Pres. Sergio Osmeña Avenue, General Santos City, South
Cotabato Branch

 Alumni ID issued from Gensantos Foundation College of General

Santos City

 Palawan Pera Padala Loyalty Card issued from Palawan Pera Padala
Pres. Sergio Osmeña Avenue, General Santos City Branch

 KCC Bonus Card issued from KCC Mall of Gensan;

2. Last August 16, 2018, upon checking my bag I noticed that the above-
described wallet is missing;

3. Despite diligent efforts, I could no longer locate, find or recover the said
wallet which contains the above-mentioned items, and to the best of my knowledge,
the same is truly lost; and

4. As such, I am executing this Affidavit of Loss to attest to the truthfulness of the

foregoing facts and use the same for whatever legal purpose it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand on ________________ in

General Santos City, Philippines.

AUGUSTINA JESSA R. ALBERCA

Affiant

SUBSCRIBED AND SWORN TO before me this __________________, in General

Santos City, Philippines, affiant exhibiting to me her competent evidence of identity by
way of Passport ID with ID No. P7692389A issued in DFA General Santos City.

Doc. No.
Page No.
Book No.
Series of 2018.