Aff. of Loss

Republic of the Philippines
CITY OF DAVAO . . . . . ..)S.S.

X----------------X
AFFIDAVIT OF LOSS
I, ESMERALDO ABOY HERNANI JR. of legal age, Filipino married

and a resident of Hillcrest Subd., Davao City, Philippines, after having
been duly sworn to depose and say:
That I am a holder of a certain PAWNPAPER duly issued by the WENADIN
PAWNSHOP, Davao City;
The said PAWNPAPER was lost and despite diligent effort to locate
hence I considered it lost;
That I am executing this affidavit and to inform the proper authorities
concerned and for whatever legal purpose this may serve.
IN WITNESS WHEREOF, I have hereunto affixed my signature this
_________day of _________________, 2013 at Davao City, Philippines.
ESMERALDO ABOY HERNANI JR.

Affiant
SUBSCRIBED AND SWORN TO before me this day of
_____________2013 at Davao City, Philippines
Doc. No._______
Page No._______
Book No._______
Series of 2013*

CITY OF DAVAO . . . . . .. )S.S.
X - - - - - - - - - - - - - - - - - - -X
AFFIDAVIT OF LOSS
I, ROQUE H. DAMASIN, JR., of legal age, Filipino and a resident of Block 18 Lot
48, Countryville Executive Homes, Cabantian, Buhangin, Davao City, Philippines, after
having been duly sworn to in accordance with law, hereby depose and say,
That I am a holder of a certain TAX RETURN, to wit:
Kinds of Return
Month
Year
2551M
February
2010
2551M
March
2010
2551M
July
2010
2551M
August
2010
2551M
September
2010
2551M
October
2010
2551M
November
2010
2551M
December
2010
2. The said TAX RETURNS were lost and despite diligent effort to locate hence I
considered them lost;
3. That I am executing this affidavit and to inform the proper authorities concerned and
for whatever legal purpose this may serve.
IN WITNESS WHEREOF, I have hereunto affixed my signature this ________day of
_____________, 2011 at Davao City, Philippines
ROQUE H. DAMASIN, JR.

Affiant
SUBSCRIBED AND SWORN TO before me this ________ day of ____________ 2011 at
Davao City, Philippines
Doc. No._______;
Page No._______;

X----------------X
Book No._______;Series of 2013
AFFIDAVIT OF LOSS
I, Lyndon Monday of legal age, Filipino married and a resident of
Barangay Tres de Mayo, Digos City, Philippines, after having been duly sworn
to in accordance with law, hereby depose and say,
That I am a holder of the following: 1) PROFESSIONAL DRIVERS
LICENSE duly issued at Land Transportation Office (LTO), Davao City;
The said DRIVERS LICENSE was lost and despite diligent effort to
locate hence I considered it lost.
That I am executing this affidavit and to inform the proper authorities
________day of _____________, 2014 at Davao City, Philippines
Lyndon Monday
Affiant
SUBSCRIBED AND SWORN TO before me this ________ day of
____________ 2014 at Davao City, Philippines
Doc. No._______
Page No._______
Book No._______
Series of 2014*
Republic of the Philippines)

X----------------X
AFFIDAVIT OF LOSS
I, JULIETA RELLEN RESERONI of legal age, Filipino married and a resident of

Purok 2, Barangay Gumalang, Baguio District, Davao City, Philippines, after having been
duly sworn to in accordance with law do hereby depose and say:
1. That I am a Day Care Teacher of Sto. Rosario Day Care Center of Barangay
Gumalang, Baguio District, Davao City and a holder of a certain one (1) unit DVD
Syntax brand model SDX-60IP and with Serial No. 12090706-10566 duly issued by
the Local Government Unit (LGU), Davao City;
2. That the said one (1) unit DVD were lost and despite of diligent efforts in
locating the same it could not be found hence, I considered it lost;
3. That I am executing this affidavit to inform the proper authorities
concerned of the foregoing facts and for whatever legal purpose this may
serve.
IN WITNESS WHEREOF, I have hereunto affixed my signatures this
________day of _____________, 2013 at Davao City, Philippines.
JULIETA RELLEN RESERONI

Affiant
SUBSCRIBED AND SWORN TO before me this ________ day of ____________

2013 at Davao City, Philippines
Doc. No._______
Page No._______
Book No._______
Series of 2013.

X----------------X
AFFIDAVIT OF LOSS
I, GREY BONANI BONA, of legal age, Filipino married and a resident of Barangay
Catigan, Toril, Davao City, Philippines, after having been duly sworn to in accordance with
law do hereby depose and say:
1. That I am a holder of a certain ATM CARD duly issued at Land Bank,
Toril Branch, Davao City;
2. That the said ATM was lost and despite of diligent efforts in locating the
same it could not be found hence, I considered it lost;
concerned of the foregoing facts and for whatever legal purpose this
may served.
GREY BONANI BONA

Affiant
Doc. No._______
Page No._______
Book No._______
Series of 2013.

X----------------X
AFFIDAVIT OF LOSS
I, ROWENA YAWAKA TAN, of legal age, Filipino married and a resident of

BLOCK 36 Lot 2 Almaciga St, Green Meadows Subdivision, Mintal, Davao City,
Philippines, after having been duly sworn to in accordance with law do hereby depose and
say:
4. That I am a holder of a certain ATM CARD duly issued at Allied Bank,
San Pedro St., Davao City;
5. That the said ATM was lost and despite of diligent efforts in locating the
may served.
ROWENA YAWAKA TAN

Affiant

Doc. No._______
Page No._______
Book No._______
Series of 2013.

X----------------X
AFFIDAVIT OF LOSS
WE, RAUL M. TOLIBAS and MANUEL AUTIDA of legal ages Filipinos, and a
resident of Davao City, Philippines, after having been duly sworn to in accordance with law
do hereby depose and say:
1. That we are officers and signatories of TRI-MEDIA ORGANIZATION FOR
PEACE AND ALLIANCE IN MINDANAO and a holder of a certain COMPANY
IDENTIFICATION CARD, duly issued by GMA Network, Inc., Davao City; PASSBOOK
duly issued by Makati Bank, ATAM CARD duly issued by Union Bank, Davao City
and DRIVERS LICENSE duly issued by Land Transportation Office, Davao City;
2. That the said ID, PASSBOOK, ATM CARD and DRIVERS LICENSE was
lost and despite of diligent efforts in locating the same it could not be found
hence, we considered it lost;
3. That we are executing this affidavit to inform the proper authorities
concerned of the foregoing facts and for whatever legal purpose this may serve.
IN WITNESS WHEREOF, we have hereunto affixed our signatures this
RAUL M. TOLIBAS
Affiant
MANUEL AUTIDA
Affiant

Doc. No._______
Page No._______
Book No._______
Series of 2013.

X----------------X
AFFIDAVIT OF LOSS
WE, BENITO JUMAMOY (Secretary/Treasurer) and TEODORICO AGRIPO
(Vice-President) of legal age Filipino, and a resident of Bankerohan,
Davao City,
say:
1. That we are officers and signatories of San Pedro Chapel Mortuary Aid
Ass., Inc. located at Bankerohan, Davao City and a holder of a certain PASSBOOK
with Acct. No. 10-017-0029765 duly issued at the Union Bank, Duterte St., Davao
City;
2. That the said PASSBOOK was lost and despite of diligent efforts in
BENITO JUMAMOY
Affiant
TEODORICO AGRIPO
Affiant

Doc. No._______
Page No._______
Book No._______
Series of 2012.

X----------------X
AFFIDAVIT OF LOSS
I, COUNCILOR VICTORIO U. ADVINCULA JR., of legal age, Filipino, married

and a resident of Libra St., Phase 3 Davao Housing Subd., Toril, Davao City, Philippines,
after having been duly sworn to in accordance with law do hereby depose and say:
1. That I am a holder of a certain SANGGUNIANG PANLUNGSOD
IDENTIFICATION CARD (ID) with Employee # 501228 duly issued at the City
Government of Davao/Sangguniang Panlungsod, Davao City;
2. That the said ID was lost and despite of diligent efforts in locating the
COUNCILOR VICTORIO U. ADVINCULA JR.,

Affiant

Doc. No._______
Page No._______
Book No._______
Series of 2012.

X ----------------X
AFFIDAVIT OF LOSS
We, PACITA IBAEZ, DULCE AMOR IBAEZ and JOLLY JAY IBAEZ all
of legal age, Filipino, and a resident of Kasilak, Bucana, Davao City,
Philippines after having been duly sworn to depose and say:
1. That we are the heirs of the late MATEO J. IBAEZ SR. who died
last February 12, 1999 at Davao City and who is a member of RHINE
PLANS CORPORATION, located at 21 Magallanes St., Cebu City;
2. That his ORIGINAL INSURANCE CERTIFICATE was lost and
despite of diligent efforts in locating the same it could not be found hence,
I considered it lost;
3. That we are executing this affidavit to inform the proper
authorities concerned of the foregoing facts and for whatever legal
purpose this may serve.
IN WITNESS WHEREOF, we have hereunto affix our signatures this
PACITA IBAEZ
Affiant
DULCE AMOR IBAEZ

Affiant
JOLLY JAY IBAEZ
Affiant

Doc. No._______
Page No._______
Book No._______
Series of 2008

X ----------------X
AFFIDAVIT OF LOSS
I, RAYNILDA DALAGUIT BONGCARAWAN, of legal age, Filipino married

and a resident of Purok 35 Lagazo Village, Calinan, Davao City,
Philippines after having been duly sworn to depose and say:
1. That I am the owner of a certain motor vehicle owned described below as, to wit:
Make & Type
Motor No.
Chassis No.
Plate No.
: MITSUBISHI
: D4BXP660447
: LO39PYZ1-09538
: LVZ553
2. That as proof of ownership of the above described vehicle I was issued by the Land
Transportation Office, Official Receipt (OR) as proof of payment and Certificate of
Registration (CR);
3. That said documents while in my position were misplaced and could no longer be
located despite of exerting efforts of locating them;
4. That the said documents were not in the position of any bank institutions or lending
companies by reason of encumbrance or chattel mortgage of the subject motor vehicle;
5. That the said documents were not confiscated by any government authorities in
violation of R.A. 4136 and other related laws:
6. That I shall assume any responsibility or liability if in any event I will use these
documents for whatever illicit transactions;
7. That I am executing this affidavit to attest to the veracity of my statements and to
support the same in its request for duplicate copies of the lost MVRR/MV/MRR/OR/CR at
the Land Transportation Office (LTO) where it has a hand over subject;
8. That I bind myself criminally civilly and administratively liable and will assume
full responsibility for nay 3rd party claim, and I hereby hold the Land Transportation Office
or any of its employees free form any liability arising from any claim for damages as a result
of the approval of the registration of the motor vehicle and or issuance of replacement
certificate of registration;
IN WITNESS WHEREOF, I have hereunto affix my signature this ________day of
_____________, 2013 at Davao City, Philippines.
RAYNILDA DALAGUIT BONGCARAWAN

Affiant
2013 at Davao City, Philippines.

X ----------------X
AFFIDAVIT OF LOSS
I,____________________________, of legal age, Filipino, married/single and a resident of

___________________________________________________, Philippines after having been duly
sworn to depose and say:
1. That I am a holder of a certain_________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
_________________
duly
issued
in
the
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
_________________________________________;
2. That said ___________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________ was inadvertently misplaced
and despite of diligent efforts in locating the same it could not be found hence, I considered it lost;
3. That I am executing this affidavit to inform the proper authorities concerned of the
foregoing
facts
and
to
request
for
the
issuance
of
a
__________________________________________________________________________________
__________________________________________________________________________________
_________ thereof in lieu of the lost one.
IN WITNESS WHEREOF, I have hereunto affix my signature this _________day of
_________________ at Davao City, Philippines.
_______________________________
Affiant
SUBSCRIBED AND SWORN to before me

______________________________ at Davao City, Philippines
this
________
day
of
Doc. No._____;
Page No. ____;
Book No. ____;
Series of 20___.

X ----------------X
AFFIDAVIT OF LOSS
I, SONIA C. MELINDO of legal age, Filipino, married and a resident of New Valencia,
Tugbok District, Davao City, Philippines after having been duly sworn to depose and say:
1. That I am the mother of CARLA C. MELINDO a 3 rd year student and a holder of a certain
SCHOOL IDENTIFICATION CARD (ID) duly issued at the Holy Cross College of Davao;
2.That said ID was inadvertently misplaced and despite of diligent efforts in locating the
3.That I am executing this affidavit to inform the proper authorities
SONIA C. MELINDO
Affiant

this
________
day
of
Doc. No._____;
Page No. ____;
Book No. ____;
Series of 2013.

X----------------X
AFFIDAVIT OF LOSS
I, LIFESTREAM INTL COLLEGE INC. represented by: FATIMA ALONZO

(President) of legal age, Filipino and business address at B2 L2 Vincent
Hts., Lanang, Davao City, after having been duly sworn to depose and
say:
1. That I am the President of LIFESTREAM INTL COLLEGE INC. and a holder
of a certain CERTIFICATE OF REGISTRATION (COR) duly issued at the Bureau of

Internal Revenue (BIR), Davao City;;
2. That the said COR was lost and despite of diligent efforts in locating the
LIFESTREAM INTL COLLEGE INC.
Affiant
represented by: FATIMA ALONZO

Doc. No._______
Page No._______
Book No._______
Series of 2013.

X----------------X
AFFIDAVIT OF LOSS
I, JOEL R. MIRAS of legal age, Filipino married and a resident of

Fortune Village, Calinan, Davao City, after having been duly sworn to
depose and say:
1. That I am the father of JOEMEL GRACE M. MIRAS 4th year student
and a holder of a certain SOLICITATION FORM duly issued at Calinan National
High School, Calinan, Davao City;
2. That the said SOLICITATION FORM was lost and despite of diligent
efforts in locating the same it could not be found hence, I considered it lost;
IN WITNESS WHEREOF, I have hereunto affixed my signatures this ______
day of ___________ 2013 at Davao City, Philippines.
Affiant
JOEL R. MIRAS
SUBSCRIBED AND SWORN TO before me this ______ day of ___________

Doc. No._______
Page No._______
Book No._______
Series of 2013.

X----------------X
AFFIDAVIT OF LOSS
I, ANALYN Q. DRAMA, of legal age, Filipino married and a resident of

Barangay Barangay Ula, Tugbok District, Davao City, after having been
duly sworn to depose and say:
1. That I am the Barangay Secretary of Barangay Ula, Tugbok District,
Davao City and a holder of a certain BARANGAY IDENTIFICATION CARD (ID)
duly issued at the Department of Interior and Local Government (DILG), Davao
City;
2. That the said ID was misplaced and despite of diligent efforts in
Affiant
ANALYN Q. DRAMA

Doc. No._______
Page No._______
Book No._______
Series of 2012.
REPUBLIC OF THE PHILIPPINES)
CITY OF DAVAO . . . . . ..
X ----------------X
)S.S.
AFFIDAVIT OF LOSS
I, CERILO S. CHATTO JR., of legal age, Filipino and a resident of Purok

2 Ilaboon, Kapalong, Davao del Norte, Philippines after having been
1. That I am the registered owner of the motor vehicle described below as, to wit:
Make & Type
Motor No.
Chassis No.
Plate No.
: HONDA
: KRZ02E014360
: KRZ02014359
: 8627LG
2. That, on October 5, 2011 I submitted the Original OFFICIAL RECEIPT (OR)

and CERTIFICTE OF REGISTRATION (CR) in the Land Transportation Office (LTO),
Davao City;
3. That the said OR and CR was lost at your end;
4. That I reconstruct again new and OR.
5. That I am executing this affidavit to attest to the truth and to inform the LTO Office
and for whatever legal purpose this may serve.
BAYANI L. EBERO
Affiant


X----------------X
AFFIDAVIT OF LOSS
I, JAMAL M. MANGADANG, of legal age, Filipino, and a resident of

Davao City, Philippines, after having been duly sworn to in accordance
with law, hereby depose and say:
That I am the registered owner and a holder of a certain ORIGINAL
Certificate No. 00183765 and ORIGINAL Certificate No. 00437256 duly
issued in the Office of Department of Trade and Industry (DTI), Davao City;
That the said ORIGINAL Certificate No. 00183765 and ORIGINAL
Certificate No. 00437256 was lost and despite of diligent efforts in locating
the same it could not be found hence, I considered it lost;
That I am executing this affidavit to inform the proper authorities
JAMAL M. MANGADANG
Affiant
Doc. No._______
Page No._______
Book No._______
Series of 2011.

X----------------X
AFFIDAVIT OF LOSS
I, ROSALINA R. JIMENEZ, of legal age, Filipino, married and a

resident of Inawayan, Davao City, Philippines, after having been duly
That I am the holder of a certain DRIVERS LICENSE duly issued in the
Land Transportation Office, (LTO), Davao City;
That the said DRIVERS LICENSE was lost and despite of diligent efforts
in locating the same it could not be found hence, I considered it lost;
Affiant
ROSALINA R. JIMENEZ

Doc. No._______
Page No._______
Book No._______
Series of 2013.

X----------------X
AFFIDAVIT OF LOSS
I, RUBY TEJANO ROSALES, of legal age, Filipino, married and a resident of

P-17Bayanihan Wangan, Calinan, Davao City, after having been duly
That I am a holder of a certain PAWNPAPER duly issued at CRISTINA DE
LEON PAWNSHOP, Calinan Branch, Calinan, Davao City;
That the aforementioned PAWNPAPER was lost and despite of diligent
Affiant
RUBY TEJANO ROSALES

Doc. No._______
Page No._______
Book No._______
Series of 2012.

X----------------X
AFFIDAVIT OF LOSS
I, DINA L. GALANG, of legal age, Filipino married and a resident of

B12, L53, Toscana, Puan, Davao City, after having been duly sworn to
depose and say:
1. That I am the mother of BRANDON L. GALANG, a first year student
who is the registered owner/holder of a certain SCHOOL IDENTIFICATION
CARD (ID) duly issued in the School of Ateneo de Davao University, High
School Department, Davao City;
2. That the said SCHOOL IDENTIFICATION CARD (ID) was lost and
despite of diligent efforts in locating the same it could not be found hence, I
considered it lost;
DINA L. GALANG,
Affiant
Doc. No._______
Page No._______
Book No._______
Series of 2010.

X----------------X
AFFIDAVIT OF LOSS
I, GIRLIE AMOR C. CAEDO, of legal age, Filipino and a resident of

Purok Crossing, Barangay Tagakpan, Tugbok District, Davao City, after
having been duly sworn to depose and say:
1. That I am a holder of a certain PRC LICENSE IDENTIFICATION CARD
(ID) duly issued in the Professional Regulation Commission (PRC),Davao City.
Affiant
GIRLIE AMOR C. CAEDO

Doc. No._______
Page No._______
Book No._______
Series of 2013.

X----------------X
AFFIDAVIT OF LOSS
I, RAMON E. RODRIGUEZ, of legal age, Filipino and a resident of

Lim Extension, Digos City, Philippines after having been duly sworn to
depose and say:
That I am a holder of a certain CELLPHONE WITH SIM CARD NO.
09196696334 duly issued by SMART Telecomunication ;
That the aforementioned SIM CARD was lost and despite of diligent efforts
in locating the same it could not be found hence, I considered it lost;
Affiant
RAMON E. RODRIGUEZ

Doc. No._______
Page No._______
Book No._______
Series of 2012.

X----------------X
AFFIDAVIT OF LOSS
I, RICA YSABEL E. RODRIGUEZ, of legal age, Filipino and a

resident of Lim Extension, Digos City, Philippines after having been duly
That Davao Central Convenience Store is a holder of a certain Counter
receipt with Invoice Nos. 50008691 and 50008794 duly issued by Davao Central
Warehouse Club, Lanang Davao City ;
That the aforementioned COUNTER RECEIPTS were lost and despite of
diligent efforts in locating the same it could not be found hence, I considered it
lost;
Affiant
RICA YSABEL E. RODRIGUEZ

2012 Davao City, Philippines.
Doc. No._______
Page No._______
Book No._______
Series of 2012.

X----------------X
AFFIDAVIT OF LOSS

resident of Lim Extension, Digos City, Philippines after having been duly
That Davao Central Convenience Store is a holder of a certain PURCHASE
ORDER of invoice number 50009367 duly issued by Davao Central Warehouse
Club, Lanang Davao City ;
That the aforementioned PURCHASE ORDER of invoice were lost and
considered it lost;
Affiant

2012 Davao City, Philippines.
Doc. No._______
Page No._______
Book No._______
Series of 2012.

X----------------X
AFFIDAVIT OF LOSS
I, FEDERICO U. LIBOON, of legal age, Filipino, married and a resident

of
Purok 23-A, Isla Suerte, Times Beach, Bucana,
Davao City ,
Philippines, after having been duly sworn to depose and say:
1. That I am the holder of certain SSS IDENTIFICATION CARD (ID) duly issued in
the Office of Social Security System (SSS) Davao City;
2. That the said ID was lost and despite of diligent efforts in locating the same it
could not be found hence, I considered it lost;
foregoing facts and for whatever legal purpose this may serve.
IN WITNESS WHEREOF, I have hereunto affixed my signatures this ________day
of _____________, 2012 at Davao City, Philippines.
FEDERICO U. LIBOON
Affiant
Doc. No._____;
Page No._____;
Book No.____;
Series of 2012.

X----------------X
AFFIDAVIT OF LOSS
I, EGBERT J. ABOGADO, of legal age, Filipino, and a resident of B-16

L-46 DECA HOMES Subd., Cabantian, Davao City District, Davao City,
Philippines, after having been duly sworn to depose and say:
1. That I am the holder of certain Tagum Coop Passbook duly issued in the Office of
Tagum Cooperative, Davao City ;
2. That the said Tagum Coop Passbook was lost and despite of diligent efforts in
foregoing facts and for whatever legal purpose this may serve.
IN WITNESS WHEREOF, I have hereunto affixed my signatures this ________day
of _____________, 2010 at Davao City, Philippines.
EGBERT J. ABOGADO
Affiant

X----------------X
AFFIDAVIT OF LOSS
I, JUDANI ARLU NIKU P. CORREA, of legal age, Filipino and a resident

of Blk.3 Lot 20 Prudential Village, Daliao, Toril, Davao City, after having
1. That I am the registered owner/holder of a certain SCHOOL
IDENTIFICATION CARD (ID) duly issued in the School of University of
Southeastern Philippines (USeP), Davao City;
2. That the said SCHOOL IDENTIFICATION CARD (ID) was lost and
considered it lost;
JUDANI ARLU NIKU P. CORREA

Affiant
Doc. No._______
Page No._______
Book No._______
Series of 2010.

X----------------X
AFFIDAVIT OF LOSS
That COMMUNITY DEVELOPMENT COOPERATIVE, represented by

Coop Chairman ROMEO L. ESCAMILLA, of legal age, Filipino, with office
address at Brgy. Kapitan Tomas Monteverde St., Davao City, Philippines,
after having been duly sworn to depose and say:
1. That COMMUNITY DEVELOPMENT COOPERATIVE / C.O.R. is
the holder of a certain CERTIFICATE OF REGISTRATION (Original) duly
issued in the Office of Bureau of Internal Revenue (BIR), Davao City;
2. That the said CERTIFICATE OF REGISTRATION / C.O.R. (Original)
was lost and despite of diligent efforts in locating the same it could not be
found hence, the cooperative considered it lost;
3. That the cooperative is executing this affidavit to inform the proper
authorities concerned of the foregoing facts and for whatever legal purpose
this may serve.

COMMUNITY DEVELOPMENT COOPERATIVE

Represented by:
Coop Chairman / Affiant
ROMEO L. ESCAMILLA


X ----------------X
AFFIDAVIT OF LOSS
I, FLORENCE C. AGUILOS, of legal age, Filipino, married and a resident of

Davao City, Philippines after having been duly sworn to depose and say:
1. That I am a holder of a certain pawn paper issued by Kimsan Pawnshop,
Quimpo Blvd., Davao City with Pawn Ticket No. 111602 dated October 29, 2009.
2. That said pawn paper issued by Kimsan Pawnshop, Quimpo Blvd., Davao
City was inadvertently misplaced and despite of diligent efforts in locating the same
it could not be found hence, I considered it lost;
IN WITNESS WHEREOF, I have hereunto affix
_________day of _________________ at Davao City, Philippines.
my
signature
this
FLORENCE C. AGUILOS
Affiant

Doc. No._____;
Page No. ____;
Book No. ____;
Series of 2010
this
________
day
of

X ----------------X
AFFIDAVIT OF LOSS
I, TIARA ANN U. WAGAY, of legal age, Filipino, single and a resident of

Purok 1, Lacson, Calinan, Davao City, Philippines after having been duly sworn to
depose and say:
1. That I am a holder of a certain OFFICIAL RECEIPT (OR) of YEAR BOOK
duly issued at the School of Mindanao Medical Foundation College, R. Castillo,
Agdao Davao City;
2. That said OR was inadvertently misplaced and despite of diligent efforts in
3.

TIARA ANN U. WAGAY

Affiant
SUBSCRIBED AND SWORN to before me this

Doc. No._____;
Page No. ____;
Book No. ____;
Series of 2010
________
day
of

X ----------------X
AFFIDAVIT OF LOSS
I, RODESSA CHI, of legal age, Filipino, and a resident of Malvar St., Davao
City, Davao City, Philippines after having been duly sworn to depose and say:
1. That I am a holder of a certain Pawn Paper Ticket issued by EURO
CIRCLE Pawnshop located at 164 Betty Tan Bldg., Anda and San Pedro St., Davao
City
2. That said pawn paper issued by EURO CIRCLE Pawnshop was
inadvertently misplaced and despite of diligent efforts in locating the same it could
not be found hence, I considered it lost;
3.

RODESSA CHI
Affiant
SUBSCRIBED AND SWORN to before me this

Doc. No._____;
Page No. ____;
Book No. ____;
Series of 2010
________
day
of

X----------------X
AFFIDAVIT OF LOSS
I, QUINTIN A. DAGOC, of legal age, Filipino married and a resident of

Adecor Kaputian, Island Garden City of Samal, Philippines after having
1. That I am the registered owner/holder of certain GSIS E-Card ID NO.
B42JHQAD011 duly issued in the GSIS Office, Davao City;
2. That the aforementioned GSIS E-Card were lost and despite of diligent
efforts in locating the same, it could not be found hence, I considered it lost;
QUINTIN A. DAGOC
Affiant
Doc. No._______
Page No._______
Book No._______
Series of 2010.

X----------------X
AFFIDAVIT OF LOSS
I, VIRGINIA L. GOLIMLIM, of legal age, Filipino married and a resident

of SIR Teachers Village, Tigatto, Buhangin, Davao City, Philippines after
1. That I am the owner/holder of a certain PASSBOOK duly issued at
Tagum Cooperative, Bajada Branch, Davao City;
2. That the aforementioned PASSBOOK were lost and despite of diligent
efforts in locating the same, it could not be found hence, I considered it lost;
Affiant
VIRGINIA L. GOLIMLIM

Doc. No._______
Page No._______
Book No._______
Series of 2013.

X----------------X
AFFIDAVIT OF LOSS
I, RONALD A. MARANTE, of legal age, Filipino, married , and a

resident of Manggahan St., Toril, Davao City, after having been duly
1. That I am the registered owner/holder of the following: SSS
IDENTIFICATION CARD (ID), duly issued at the Social Security system
(SSS), Davao City, 2) DRIVERS LICENSE duly issued at Land Transportation
Office (TO), Davao City; 3) SECURITY OFFICERS LICENSE, AFPSLAI
IDENTIFICATION CARD (ID); 4) FIREARM LICENSE and TIN IDENTIFICATION
CARD (ID) duly issued at the Bureau of Internal Revenue (BIR), Davao City
and other pertinent documents.
2. That the aforementioned IDs and LICENSE was lost and despite
of diligent efforts in locating the same, it could not be found hence, I
considered it lost;
3. That I am executing this affidavit to inform the proper
authorities concerned of the foregoing facts and for whatever legal
purpose this may serve.
______ day of ___________ 2012 at Davao City, Philippines.
RONALD A. MARANTE
Affiant
SUBSCRIBED AND SWORN TO before me this ______ day of
___________ 2012 at Davao City, Philippines.
Doc. No._______
Page No._______
Book No._______
Series of 2012.

X ----------------X
AFFIDAVIT OF LOSS
I, SANITARY CARE PRODUCTS ASIA INC. represented by: RICHARD

ALVIN PULIDO (Head Logistic) of legal age, Filipino and a resident of
Lanang, Davao City, Philippines after having been duly sworn to depose
and say:
1. That SANITARY CARE PRODUCTS ASIA INC. is the registered owner of a
certain motor vehicle described below as, to wit:
Make & Type
Motor No.
Chassis No.
Plate No.
: KIA
: J2-494161
: KNQSE211287323263
: LGH415
Registration (CR);
SANITARY CARE PRODUCTS ASIA INC.
represented by: RICHARD ALVIN PULIDO
Affiant


X----------------X
AFFIDAVIT OF TWO DISINTERED PERSONS

RE: LOSS OF LAPTOP
WE, ME-ANN D. BIOLON and MARY GRACE L. GARCIA, both of legal

ages, Filipinos, married and a resident of Davao City, Philippines, after
having been duly sworn to in accordance with law, hereby depose and
say,
That we are employees of Sangguniang Panlungsod, Davao City, and we know that
Councilor Peter Lavina is a holder of one (1) unit LAPTOP ASUS and M.R. to him and
owned by City Government of Davao with property #06-0696;
That Mary Ann B. Gonzales, one of the staff of Councilor Peter Lavina is the one
who discovered that the LAPTOP ASUS was lost and despite diligent efforts to locate the
same they cannot be found hence, they considered it lost.
3. That we are executing this affidavit to inform the proper authorities concerned of
the foregoing facts and for whatever legal purpose this may serve.
ME-ANN D. BIOLON
Affiant
MARY GRACE L. GARCIA

Affiant

Doc. No._______
Page No._______
Book No._______
Series of 2010.

X ----------------X
AFFIDAVIT OF LOSS
I, EVELYN P. SASUBE, of legal age, Filipino, married and a resident of

Mitsui Busan Vill., Bajada, Davao City, Philippines after having been
Make & Type : HONDA
Motor No.
: XRM16E084746
Chasis No
: XRM16084740
Plate No.
: _5295YL
Registration (CR);
located inspite of exerting efforts of locating them;
EVELYN P. SASUBE
Affiant

X----------------X
AFFIDAVIT OF LOSS
I,
A M A COMPUTER COLLEGE, INC., represented by NONITO R.

LAVESORES JR. of legal age, Filipino, and with office address at
Marfori Heights, Davao City, Philippines, after having been duly
That A M A COMPUTER COLLEGE, INC., is a holder of a certain

ORIGINAL CERTIFICTE OF REGISTRATIOPN (COR) Form No. 1556 duly issued
in the Bureau of Internal Revenue (BIR), Davao City.
That the said ORIGINAL CERTIFICTE OF REGISTRATIOPN (COR ) was
lost and despite of diligent efforts in locating the same it could not be found
hence, I considered it lost;
A M A COMPUTER COLLEGE, INC.,

represented by : NONITO R. LAVESORES JR.
Affiant

Doc. No._______
Page No._______
Book No._______
Series of 2011.

X ----------------X
AFFIDAVIT OF LOSS
I, ALDIEN M. SARUNAY, of legal age, Filipino, married and a resident

of Lansona Hi-way, Calinan, Davao City, Philippines after having been
That I am the owner of a certain TWO (2) PAWNPAPER with PT #40942 and
PT #40941 duly issued at De Leon Pawnshop Calinan Branch, Davao City;
2. That the said PAWNPAPER was inadvertently lost and despite of diligent
4. That I am executing this affidavit to inform the proper authorities concerned
and for whatever legal purpose this may serve.
ALDIEN M. SARUNAY
Affiant
Doc. No._______
Page No._______
Book No._______
Series of 2012

X----------------X
JOINT AFFIDAVIT OF LOSS
We, REBECCA S. DIZON (Vice-President of-Admin & Operations) of

legal age, Filipino and a resident of Davao City and MARGE FLORITA C.
IBAEZ of legal age, Filipino and a resident of Davao City, Philippines
after having been duly sworn to depose and say:
1. That we are employee of Davao Beta Spring, Inc. located Malagamot
Road, Panacan, Davao City and holder of a certain SAFETY DEPOSIT VAULT
KEY NO. K-1509 of BPI-Quirino Branch, Davao City;
2. That the said SAFETY DEPOSIT VAULT KEYS NO. K-1509 were lost
after the robbery incident happened last August 7, 2010 at around 2:00 A.M. at
the residence of Marge Florita C. Ibaez;
3. That we are requesting the BPI-Quirino Branch Office, Davao City to
force open the Safety Deposit Vault;
3. That we are executing this affidavit to inform the proper authorities

REBECCA S. DIZON
MARGE FLORITA C.
IBAEZ
Affiant
Affiant

Doc. No._______
Page No._______
Book No._______
Series of 2010.

X ----------------X
AFFIDAVIT OF LOSS
I, MD BIOTECH & RESEARCH CORP., of legal age, Filipino and a

resident of Sto. Tomas , Davao del Norte, Philippines after having been
1. That the corporation is the registered owner of the motor vehicle described below
as, to wit:
Make & Type : NISSAN
Motor No.
: TD27TD02391
Chasis No.
Plate No.
:
: LEG457
Registration (CR);
MD BIOTECH & RESEARCH CORP
Affiant

X ----------------X
AFFIDAVIT OF LOSS
I, BARANGAY TUGBOK PROPER represented by LENNIE R. REPALDA
(Barangay Treasurer) of legal age, Filipino, and a resident of Barangay
Tugbok Proper, Davao City, Philippines, after having been duly sworn to
depose and say:
That BARANGAY CTUGBOK PROPER is a holder of a certain OFFICIAL

RECEIPT (OR) duly issued in the Office of BAYAN TELECOMMUNICATIONS
INC., Davao City;
2. That the said OFFICIAL RECEIPT (OR) was inadvertently lost and
considered it lost;
4. That I am executing this affidavit to inform the Register of Deeds of Davao
City and for whatever legal purpose this may serve.
BARANGAY TUGBOK PROPER

represented by:
LENNIE R. REPALDA
Affiant
Doc. No._______
Page No._______
Book No._______
Series of 2011

CITY OF DAVAO . . . . . . . . . . . . .)S.S.
x- - - - - - - - - - - - - - - - - - - - - - x
AFFIDAVIT OF LOSS
I, GARLON A. ICASAS of legal age, Filipino and a resident of Old Airport,
Sasa, Davao City , after being sworn to in accordance with law, hereby
depose and say, THAT:
1. The subject motor vehicle is described as follows:
Make/Type HI BED
C.R. No.04922594
Motor No.
Current O.R. No.___________
Chassis No. LTC-4PE-1716
File No.4pe 22755
Plate No. NUR-659
Classification______________
Trade No._________________________________
Position of Affiant :/ /Chairman / / General Manager
/ / President /X / Owner
2. On or about _______AM/PM of ____________________my vehicle was properly
parked at ________________________________. When I returned to retrieve the
above-described vehicle on _____________, I noticed that one/both of its
plates is/are missing.
3. I lost no time in diligently trying t locate the said plates but all efforts
exerted proved futile and to no avail and that the same is considered lost or
stolen and beyond recovery.
4. The said lost plate/s was/were never lent to another person or entity nor
confiscated by any other law enforcement agency.
5. I bind myself to surrender the said plates to the district office that issued the
same in the event that said plates are recovered;
6. If the DOTC thru the LTO/LTFRB, after inquiry, has found me responsible
for the unauthorized of the herein reported lost plates, I hereby signify my
conformity to be meted the administrative fines and penalties due and
imposed thereon, including the grounding of the unit/s covered by the
Certificate of the Public Convenience issued therefore, with waiver and
desistance on my part for any claim or action reason on the aforesaid
punitive measures taken against me.
7. Purpose of the affidavit of Loss:
/ /For LTFRB Petition for Dropping and Substitution
/ / For LTFRB Petition for Sale and Transfer and/or
/X / For Securing a replacement for lost plates.
8. I am executing this affidavit for the aforesaid purposes as well as for
attesting to the truth of the statements herein declare subject to the rules on
perjury.
AFFIANT FURTHER SAYETH NAUGHT.
GARLON A. ICASAS
Affiant
SUBSCRIBED AND SWORN to before me this _______ day of________ at Davao

City, Philippines, affiant exhibited to me his/her CTC No.________ issued on
______________ at_______________.

X ----------------X
AFFIDAVIT OF LOSS
I, ROLANDO SEPADA BASCO, of legal age, Filipino married and a resident

of Blk. 16 Lot 10, Ilang-Ilang St., Phase II, Tugbok, Davao City, Philippines after
1. That I am the owner of a certain HOUSE located at Blk. 16 Lot 10, IlangIlang St., Phase II, Tugbok, Davao City;
2.That said HOUSE was burned last March 16, 2012;

1. That the damaged of my house will cost P 923,499.22.
ROLANDO SEPADA BASCO

Affiant
SUBSCRIBED AND
SWORN
to
before
me
Doc. No._____;
Page No. ______;
Book No. ______;
Series of 2012*
this
________
day
of

X----------------X
AFFIDAVIT OF LOSS
I,
JOSE LEON VENCER, of legal age, Filipino, single and a resident of

Guerrero St., Davao City, after having been duly sworn to depose
and say:
That I am the holder of a certain PHILIPPINE PASSPORT , duly issued in

the Office of Department of Foreign Affairs (DFA), General Santos City;
That the aforementioned PASSPORT was lost and despite of diligent
Affiant
JOSE LEON VENCER

Doc. No._______
Page No._______
Book No._______
Series of 2010.

X----------------X
AFFIDAVIT OF LOSS
I, GIDEON QUIONES FEROLINO, of legal age, Filipino, and a resident of

8th Ave., Bangoy St., Brgy. Tomas Monteverde Sr., Davao City, after
1. That I am the holder of a certain PHILHEALTH IDENTIFICATION CARD
(ID) duly issued in the Philhealth Office of Davao City;
2. That the said ID was misplaced and despite of diligent efforts in
GIDEON QUIONES FEROLINO

Affiant
Doc. No._______
Page No._______
Book No._______
Series of 2011.

City of Davao. . . . . . . . . . )s.s.
X- - - - - - - - - - - - - - - - - X
AFFIDAVIT OF LOSS
I, NILO BALBIN of legal age, Filipino married and a resident of Bo. Obrero,
Davao City, Philippines after having been duly sworn to depose and
say:
Make & Type
Motor No.
Chasis No.
Plate No.
: HONDA
: XRM110ME7182766
: XRM12-063-182766
: MEB223
Registration (CR);
NILO BALBIN
Affiant

X ----------------X
AFFIDAVIT OF LOSS
I, ____________________________________________, of legal age, Filipino

____________________ and a resident of ________________________________
______________________________________________________________________
_______________________, Philippines after having been duly sworn to
depose and say:
1. The subject motor vehicle is described as follows::
Make & Type : ___________________
Motor No.
: ___________________
Chasis No.
: ___________________
Plate No.
: ___________________
Trade Name :____________________
Position of Affiant
: :Chairman
: : President
C.R. No._____________
Current O.R. No.____________
File No.___________________
Classification_______________
: : General Manager
: : Owner
2. On or about ________AM/PM of _______________, my vehicle was properly

parkedat ________________________________________.When I returned to retrieve the
above-described vehicle on____________________, I noticed that one/both of its plates
is/are missing.
3. I lost no time in diligently trying to locate the said plates but all efforsts exerted
proved futile and to no avail and that the same is considered lost or stolen and beyond
recovery.
4. The said lost plate/s was/were never lent to another person or entity nor confiscated
by any other law enforcement agency.
5. I bind myself to surrender the said plates to the district office that issued the same
in the event that said plates are recovered;
6. If the DOTC thru the LTO/LTFRB, after inquiry, has found me responsible for the
unauthorized of the herein reported lost plates, I hereby signify my conformity to be meted
the administrative fines and penalties due and imposed thereon, including the grounding of
the unit/s covered by the Certificate of the Public Convenience issued therefore, with waiver
and desistance on my part for any claim or action by reason on the aforesaid punitive
measures taken against me.
7. Purpose of this affidavit of Loss:
: : For LTFRB Petition for Dropping and Substitution
: : For LTFRB Petition for Sale and Transfer and/or
: : For Securing a replacement for lost plates.
8.I am executing this affidavit for the aforesaid purposes as well as for attesting to the
truth of the statements herein declared, subject to the rules on perjury.
AFFIANT FURTHER SAYETH NAUGHT.
__________________________
Affiant

X----------------X
AFFIDAVIT OF LOSS
I, RICA YSABEL E. RODRIGUEZ, of legal age, Filipino and a resident of

2269 Gen. Lim Extension, Digos City, Davao del Sur, after having
That I was a Superstore Coordinator for the Davao City Area from July 30,
2009 and Jan. 31, 2011 of the S Activations and Consultancy, Inc. located at
Door 5 Aala Bldg, Camia St., Corner Juan Ave., Matina, Davao City;
That by virtue of said position, I possess the Official Receipts (O.R.) duly
issued by S Activations and Consultancy, Inc. for Unilever Philippines, located at
U.N. Avenue, Metro Manila, to be used for Liquidation purposes, briefly described
as follows:
O.R NO.
AMOUNT
436710
P
207.50
2362
1, 500.00
38299
10, 169.00
9862272A
900.00
49659
500.00
037204
1, 200.00
That the said Official Receipts for Liquidation were lost and despite of
diligent efforts in locating the same it could not be found hence, I considered it
lost;
Affiant

Doc. No._______
Page No._______
Book No._______
Series of 2011.
CITY OF DAVAO . . . . . ..
X ----------------X
)S.S.
AFFIDAVIT OF LOSS
I, ROBERT BALON AGUSTIN of legal age, Filipino married and a resident

of Purok 6 Dacudao, Calinan, Davao City, Philippines after having
Make & Type
Motor No.
Chassis No.
Plate No.
: MITSUBISHI
: AQ2374
:
: MCM553
Registration (CR);
ROBERT BALON AGUSTIN

Affiant

X----------------X
AFFIDAVIT OF LOSS
I, MIRASOL UY OPALLA , of legal age, Filipino, married and a resident of

Blk. 8, Lot2, Suraya Homes, Cabantian, Davao City, Philippines, after
That I am the mother of IAN UY OPALLA holder of a certain SCHOOL
IDENTIFICATION CARD (ID) duly issued in the Ateneo de Davao High School
Department, Davao City.
That the said SCHOOL IDENTIFICATION CARD (ID), was lost and
considered it lost;
Affiant
MIRASOL UY OPALLA

Doc. No._______
Page No._______
Book No._______
Series of 2010.

X ----------------X
AFFIDAVIT OF LOSS
I, JEARVE M. SAYSON of legal age, Filipino single and a resident of

Ph2 Sandawa, Matina, Davao City, Philippines after having been duly
Make & Type
Motor No.
Chassis No.
Plate No.
: GRANSTAR
: 152FMH-288401290
: 152FMH-288400703
: 2089LJ
Registration (CR);
JEARVE M. SAYSON
Affiant
Doc. No.________;
Page No.________;
Book No.________;
Series of 2012.

X----------------X
AFFIDAVIT OF LOSS

resident of Digos City, Philippines after having been duly sworn to
depose and say:
That Davao Central Warehouse Club is a holder of a certain Sales Invoice
Nos. 50000232; 50010563; 50010062; 50010063; 50009577; 50009367;
50008794 and 50008691; duly issued by Unilever RFM Ice Cream Inc. ;
That the aforementioned SALES INVOICE were lost and despite of diligent

Affiant
Doc. No._______
Page No._______
Book No._______
Series of 2012.

X----------------X
AFFIDAVIT OF LOSS
I, RICHIE BALASA ARROJADO legal age Filipino married and a resident of Mintal,
Tugbok, Davao City, Philippines, after having been duly sworn to in accordance with law do
hereby depose and say:
That I am holder of a certain TIN IDENTIFICATION CARD, duly issued at at
the Bureau of Internal Revenue (BIR), Davao City.
2. That the said TIN CARD was lost and despite of diligent efforts in
IN WITNESS WHEREOF, I have hereunto affixed my signature
this
RICHIE BALASA ARROJADO

Affiant

Doc. No._______
Page No._______
Book No._______
Series of 2013.

X----------------X
AFFIDAVIT OF LOSS
I, BAI HUNDRA CASSANDRA DOMINQUE N. ADVINCULA of legal age
Filipino, single and a resident of b5 7 Crystal Bay Road, Hillcrest Subd., Davao City,
say:
That I am the guardian of CARLO N. HAM and a holder of a certain SCHOOL
IDENTIFICATION CARD (ID) duly issued at the Davao City National High School
3. That I am executing this affidavit to attest to the truth and to inform the
proper authorities concerned and for whatever legal purpose this may serve.
IN WITNESS WHEREOF, I have hereunto affixed my signature
this
BAI HUNDRA CASSANDRA DOMINQUE N. ADVINCULA

Affiant

Doc. No._______
Page No._______
Book No._______
Series of 2012.

X ----------------X
AFFIDAVIT OF LOSS
I, RENATO ALDEMITA BASALE of legal age, Filipino, married and a resident of Purok
Everlasting, Barangay Tagakpan, Tugbok District, Davao City, Philippines after having been duly
That I am a holder of a certain SSS IDENTIFICATION CARD (ID) duly issued by the Social
Security System (SSS), Davao City;
That aforesaid ID was inadvertently misplaced and despite of diligent efforts in locating the

RENATO ALDEMITA BASALE

Affiant

Doc. No._____;
Page No. ____;
Book No. ____;
Series of 2013.
this
________
day
of

Aff. of Loss

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Republic of the Philippines

CITY OF DAVAO . . . . . ..)S.S.

I, ESMERALDO ABOY HERNANI JR. of legal age, Filipino married

ESMERALDO ABOY HERNANI JR.

Republic of the Philippines

ROQUE H. DAMASIN, JR.

Republic of the Philippines

Book No._______;Series of 2013

Republic of the Philippines)

I, JULIETA RELLEN RESERONI of legal age, Filipino married and a resident of

JULIETA RELLEN RESERONI

SUBSCRIBED AND SWORN TO before me this ________ day of ____________

Republic of the Philippines)

GREY BONANI BONA

Republic of the Philippines)

I, ROWENA YAWAKA TAN, of legal age, Filipino married and a resident of

ROWENA YAWAKA TAN

SUBSCRIBED AND SWORN TO before me this ________ day of ____________

Republic of the Philippines)

SUBSCRIBED AND SWORN TO before me this ________ day of ____________

Republic of the Philippines)

SUBSCRIBED AND SWORN TO before me this ________ day of ____________

Republic of the Philippines)

I, COUNCILOR VICTORIO U. ADVINCULA JR., of legal age, Filipino, married

COUNCILOR VICTORIO U. ADVINCULA JR.,

SUBSCRIBED AND SWORN TO before me this ________ day of ____________

Republic of the Philippines)

DULCE AMOR IBAEZ

SUBSCRIBED AND SWORN TO before me this ________ day of

Republic of the Philippines)

I, RAYNILDA DALAGUIT BONGCARAWAN, of legal age, Filipino married

RAYNILDA DALAGUIT BONGCARAWAN

Republic of the Philippines)

I,____________________________, of legal age, Filipino, married/single and a resident of

SUBSCRIBED AND SWORN to before me

Republic of the Philippines)

SUBSCRIBED AND SWORN to before me

Republic of the Philippines)

I, LIFESTREAM INTL COLLEGE INC. represented by: FATIMA ALONZO

of a certain CERTIFICATE OF REGISTRATION (COR) duly issued at the Bureau of

LIFESTREAM INTL COLLEGE INC.

represented by: FATIMA ALONZO

SUBSCRIBED AND SWORN TO before me this ________ day of ____________

Republic of the Philippines)

I, JOEL R. MIRAS of legal age, Filipino married and a resident of

SUBSCRIBED AND SWORN TO before me this ______ day of ___________

Republic of the Philippines)

I, ANALYN Q. DRAMA, of legal age, Filipino married and a resident of

SUBSCRIBED AND SWORN TO before me this ______ day of ___________

REPUBLIC OF THE PHILIPPINES)

I, CERILO S. CHATTO JR., of legal age, Filipino and a resident of Purok

2. That, on October 5, 2011 I submitted the Original OFFICIAL RECEIPT (OR)

SUBSCRIBED AND SWORN TO before me this ________ day of ____________

Republic of the Philippines)

I, JAMAL M. MANGADANG, of legal age, Filipino, and a resident of

Republic of the Philippines)

I, ROSALINA R. JIMENEZ, of legal age, Filipino, married and a

SUBSCRIBED AND SWORN TO before me this ______ day of ___________

Republic of the Philippines)

I, RUBY TEJANO ROSALES, of legal age, Filipino, married and a resident of

RUBY TEJANO ROSALES

SUBSCRIBED AND SWORN TO before me this ______ day of ___________

Republic of the Philippines)

SUBSCRIBED AND SWORN TO before me this day of ____

SUBSCRIBED AND SWORN TO before me this day of ____

SUBSCRIBED AND SWORN TO before me this day of ____

SUBSCRIBED AND SWORN TO before me this day of ____

SUBSCRIBED AND SWORN TO before me this day of ____

SUBSCRIBED AND SWORN TO before me this day of ____

SUBSCRIBED AND SWORN TO before me this day of _____

SUBSCRIBED AND SWORN TO before me this day of _____

SUBSCRIBED AND SWORN TO before me this day of ____

SUBSCRIBED AND SWORN TO before me this day of _____

SUBSCRIBED AND SWORN TO before me this day of _____

SUBSCRIBED AND SWORN TO before me this day of _____

SUBSCRIBED AND SWORN TO before me this day of _____

SUBSCRIBED AND SWORN TO before me this day of _____

SUBSCRIBED AND SWORN TO before me this day of _____

SUBSCRIBED AND SWORN TO before me this day of _____

SUBSCRIBED AND SWORN TO before me this day of ____

SUBSCRIBED AND SWORN TO before me this day of ____

SUBSCRIBED AND SWORN TO before me this day of _____

SUBSCRIBED AND SWORN TO before me this day of ____