REPUBLIC OF THE PHILIPPINES)

PROVINCE OF NUEVA VIZCAYA) S.S.

MUNICIPALITY OF BAYOMBONG)

AFFIDAVIT OF LOSS

I, MA. BELLA J. VILLANUEVA, of legal age, widow, Filipino

citizen, and a resident of Bonfal West, Bayombong, Nueva Vizcaya, after
having been duly sworn to in accordance with law hereby depose and state:

1. That I am a bonafide holder of Mutual Retirement Benefit System

(MRBS) certificate and Mutual Aid System (MAS) certificate issued by
Philippine Public School Teachers Association,, located at 245 Banawe
St., Quezon City;

2. That sometime in last week of August 2017, the said certificates were
inadvertently lost and despite earnest exerted efforts, I failed to find them
anymore;

3. That finding the futility of recovering the said certificates, it is hereby

declared that the same are considered lost and beyond recovery;

4. That I attest to the veracity of the foregoing statements and hereby execute
this affidavit for the purpose of securing another Certificates in lieu of the
lost one.

IN WITNESS WHEREOF, I have hereunto set my hand on this

affidavit this 4th day of September 2017 at Bayombong, Nueva Vizcaya.

MA. BELLA J. VILLANUEVA

Affiant
OSCA Identification Card No. HB-0472

SUBSCRIBED AND SWORN TO before me this 4th day of

September 2017, at Bayombong, Nueva Vizcaya. Affiant having exhibited to
me her competent identification card, indicated below her name and signature.