Republic of the Philippines)

Province of Eastern Samar)S.S.

Municipality of Dolores)

AFFIDAVIT OF LOSS

I, CARLOTA MACATIMPAG DUARTE, 61 years old, married, resident of

Barangay Cabagoan, Dolores, Eastern Samar, after having been duly sworn according to
law, hereby depose and state:

1. That on June 8, 2017 at around 8:00 oclock in the morning, we went home to
our transient house together with my wife in Barangay 2, Dolores, Eastern
Samar, after spending my birthday celebration.

2. That after going home, I noticed my wallet placed inside my pocket was lost.
The wallet contains my Landbank ATM card, Social Security System
Identification card, Senior Citizen Identification Card, Tax Identification card and
other personal possessions.

3. That diligent search of said wallet proved futile and unavailing.

4. That for all legal intent and purpose the same is lost and beyond recovery.

5. That I am executing this affidavit to attest the foregoing factual statements.

CARLOTA M. DUARTE
Affiant

SUBSCRIBED AND SWORN to before me this 9th day of June 2017 in Dolores,
Eastern Samar, affiant exhibiting to me his _____________________________________
issued on ________________________ at ____________________________________.

Doc. No. _____

Page No. _____
Book No. _____
Series of 2017.