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REPUBLIC OF THE PHILIPPINES)

____________________________) S.S.

AFFIDAVIT OF LOSS
I, JUAN C. DELA CRUZ, of legal age, single, Filipino, and with residence and
postal address _____________________ after having been duly sworn to in accordance
with law, hereby depose and state:

1. That I am the holder of the following:

a.) Unified Multi-Purpose Id (UMID), issued to me by Social Security


System, (SSS);

b.) Company Identification card issued to me by HC Finance


Consumer Philippines, with office address at Dasmariñas City,
and;

c.) High School Diploma, issued to me by Noveleta National High


School, Batch 2006.

2. That sometime on July 2017, the said identification cards and High
School Diploma that I kept in the cabinet was among those
belongings that I lost when our place was heavily flooded due to
“habagat”;

3. That the torrential rains caused the unexpectedly sudden and


devastating flow of very high flood water that inundated thousands of
residential houses including my place;

4. That during that time, we were not able to save all our belongings;

5. That after the heavy rains and flood, as I was making an inventory,
the said documents were missing;

6. That I exerted diligent and thorough efforts to look for the missing
identification cards and High School Diploma, but the same proved
futile;

7. That in view of this incident, it is now impossible to recover the said


identification cards and High School Diploma ;

8. That I executed this Affidavit of Loss to attest to the truth of the


foregoing facts and circumstances for whatever legal purposes this
may serve.

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


at _____________.

JUAN C. DELA CRUZ

Affiant

SUBSCRIBED AND SWORN to before me this ______________ at


_______________ Affiant exhibited to me his TIN _________________, issued by
Bureau of Internal Revenue (BIR).

Doc No. ________;


Page No. _______;
Book No. _______;
Series of 2018.