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Republic of the Philippines)

Olongapo City .) S.S.

AFFIDAVIT OF LOSS
I, SUSAN P. GRIMM, of legal age, married, Filipino, and presently residing at
No. 120 H Echo St., Binictican Drive, Subic bay Freeport Zone, Philippines, after having
duly sworn to in accordance with law, hereby depose and state, that:
1.

I am the Vice-President of PRINTING IMAGES COAST TO COAST,


located at Subic Bay Freeport Zone (SBFZ);

2.

That sometime in 2010, we transfer office from another location;

3.

That sometime last week, I went over my personal documents and I


found out that my GENERALI PHILIPPINES insurance policy with Policy
Insurance No. 92020999 where I had deposited certain amounts of
money under my account thereat was missing, and I assumed that the
same was lost during the transport of our office documents from our old
office to the new one;

4.

Despite diligent effort to locate the same, all efforts proved fruitless as up
to the present and fear that the same has been lost beyond recovery; and

5.

I am executing this affidavit of loss to attest to the truth of the foregoing


and for whatever legal purpose it may serve.

AFFIANT FURTHER SAYETH NAUGHT.


IN WITNESS WHEREOF, I have hereunto affix my signature this 22 nd day of
January 2014 at Subic Bay Freeport Zone, Olongapo City, Philippines.

SUSAN P. GRIMM
- Affiant SUBSCRIBED AND SWORN to before me this 22nd day of January 2014 at
Subic Bay Freeport Zone. Affiant exhibited to me her LTO Non-Professional Drivers
License No. C13-95-022380 as proof of her personal identification.
Doc No.: 127;
Page No. 27;
Book No.
1;
Series of 2014.