Republic of the Philippines )

Camiling, Tarlac
) S.S.

AFFIDAVIT OF LOSS
I, REMEDIOS M. GARBIN, 65 years old, married, Filipino citizen and a
resident of Barangay Malacampa, Camiling, Tarlac, Philippines, after having
been duly sworn to in accordance with law, do hereby depose and state THAT:
1. Sometime in December 5, 2016, I requested for authenticated copies of
my Certificate of Live Birth and Marriage Contract from the Philippine
Statistics Authority (PSA) and paid for it at the Savemore Camiling,
Tarlac branch. I was then issued an Official Receipt which will serve as
my claim stub;
2. After my transaction, I placed the said receipt inside my wallet and
went home;
3. Earlier today, when I was about to claim the above-mentioned
certificate of live birth and marriage contract, I discovered that the
receipt was missing in my wallet;
4. I thoroughly searched for the missing receipt but I found nothing. I
looked for it in my cabinets inside our house where the said receipt
might have been transferred but it was in vain. I also asked the
members of our household if they have seen the said receipt but all
answered in the negative;
5. All my efforts to locate the said receipt proved futile; hence, I now
consider the same as lost and beyond recovery;
6. I am executing this Affidavit to attest to the truthfulness of the foregoing
statements and for all legal intents and purposes it may serve.
IN WITNESS WHEREOF, I have hereunto affixed my signature this 5th day
of January, 2017 at Camiling, Tarlac, Philippines.
REMEDIOS M. GARBIN
Affiant
SUBSRCRIBED AND SWORN to before me on the date and place
indicated above. Affiant exhibited before me her Senior Citizen ID Card with
Control No. 4797 issued by the Office for Senior Citizen Affairs, Camiling, Tarlac.

Doc. No.________;
Page No.________;
Book No.________;
Series of 2017.