Republic of the Philippines )

Camiling, Tarlac ) S.S.

AFFIDAVIT OF LOSS
I, JINIE RAGSAC GOROSPE, 26 years old, single, Filipino citizen, and a
resident of Barangay Bilad, Camiling, Tarlac, Philippines, after having been duly
sworn to in accordance with law, do hereby depose and state THAT:

1. On June 7, 2017 in the afternoon, after reaching home, I discovered that

my wallet which I earlier placed inside my shoulder bag, was missing;

2. My wallet contained some cash, my SSS Unified Multi-Purpose ID Card

(SSS UMID Card), Voter ID Card issued by the COMELEC, Camiling,
Tarlac and other personal belongings;

3. Immediately, I thoroughly search the contents of my bag hoping that my

wallet was mixed with my other personal belongings but I found nothing.
Also, I went to the bus terminal in Camiling Town Proper, Camiling, Tarlac
to look for the bus I boarded from Pampanga but it was not there
anymore;

4. All efforts exerted to locate the said wallet containing my SSS UMID Card
and Voter ID Card proved futile; hence, I now consider them as lost and
beyond recovery;

5. The said ID cards were never pledged or used as a security to any

obligations;

6. I am executing this affidavit to attest to the truth of the foregoing

statements and for whatever legal intents and purposes this may serve.

IN WITNESS WHEREOF, I have hereunto affixed my signature this 7th day of

July, 2017 at Camiling, Tarlac, Philippines.

JINIE R. GOROSPE
Affiant

SUBSCRIBED AND SWORN to before me on the date and place indicated

above. Affiant exhibited before me her Philippine Passport with Number
EC5038099 issued by the Department of Foreign Affairs, Manila on August 15,
2015, valid until August 14, 2020.

Doc. No._______;
Page No._______;
Book No.______;
Series of 2017.