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Republic of the Philippines )

Cainta, Rizal ) SS.

AFFIDAVIT OF LOSS
I, MARK JOSHUA BELARMINO PAGSUYOIN, Filipino, of legal age, single, and a
resident of B 17 L 18 PH-2B Barangay San Luis, Antipolo City, Rizal, under oath do hereby
depose and state, that:

I hold documents duly issued by the Municipality of Cainta, to wit:

a. Mayors Permit; and


b. Health Permit.

It so happened, however, that my bag was stolen along with said Mayors and
Health Permits which were contained therein and is nowhere to be found;

I declare under penalties of perjury that this affidavit has been made in good
faith verified by me and to the best knowledge and belief is true and correct;

Earnest efforts were exerted on my part to retrieve the same but to no avail;

This affidavit is being executed to attest to the veracity of the foregoing


instrument in order to establish the existence of the above-mentioned Permits and the
facts of its subsequent loss for purposes not contrary to law, morals, good custom and
public policy.

IN WITNESS WHEREOF, I have hereunto set my hand this 27 th day of April 2016 at
Cainta, Rizal.

MARK JOSHUA BELARMINO PAGSUYOIN


Affiant

SUBSCRIBED AND SWORN TO before me on the date and at the place above
written, affiant exhibiting to me his TIN I.D. 325-501-938-000 bearing a his photo and
signature as competent evidence of identity.

Doc. No. ; Atty. CESAR R. LOPEZ, JR.


Page No. ; NOTARY PUBLIC
Book No. ; Valid until December 31, 2017
Series of 2016. PTR No. 4961303/Jan. 5, 2016/Rizal
IBP No.1009445/ Sept. 18, 2015/Rizal
Roll No. 42306