Republic of the Philippines)

Province of Southern Leyte) S. S.

Municipality of Macrohon)

AFFIDAVIT OF LOSS

I, CARMEN C. FLORES, Filipino, of legal age and a resident of

Sto. Rosario, Padre Burgos, Southern Leyte, Philippines, after having
been duly sworn to in accordance with law, do hereby depose and
say:

1. That I am a bona fide plan holder of St. Peter Life Plan, Maasin
City, Southern Leyte;

2. That relative thereto, a LPA/Contract bearing LPA No. 9577999

was issued in my favour;

3. That undesirably however, the aforesaid Original LPA/Contract

was lost sometime in the month of May, 2018;

4. That I have exerted my best efforts to locate and recover the

aforesaid Original LPA/Contract, but despite diligent search
made, my efforts proved futile. I now consider the same
irretrievably lost;

5. That I am executing this affidavit to attest to the veracity of

the foregoing particularly to prove the loss of the above-
mentioned Original LPA/Contract.

IN WITNESS WHEREOF, I have hereunto set/affixed my

signature this 16th day of July 2018 at Macrohon , Southern Leyte,
Philippines.

CARMEN C. FLORES
Affiant
OSCA (Padre Burgos) ID 2183871
issued on May 19, 2003

SUBSCRIBED AND SWORN TO before me this 16th day of July

2018 at Macrohon, Southern Leyte, Philippines.

ATTY. MENCHIE ANN S. SALINAS

Notary Public
Com. No. 2017-10 UNTIL Dec. 31, 2018
Roll of Attorneys No. 66790
Doc. No. ____ IBP No. 021495; 1/05/18; Pasig City
Page No. ____ PTR No. 6073809; 1/04/18; Maasin
City
Book No. ____Series of 2018 Macrohon, Southern Leyte