REPUBLIC OF THE PHILIPPINES)

Glan, Sarangani Province ) S.S.

AFFIDAVIT OF LOSS
I, CHARISSA MAE L. TABANAO, of legal age, Filipino, single and a
resident of Block 10 Lot 30 Phase A, Habitat, Mabuhay, General Santos City,
Philippines, after having first been duly sworn to in accordance with law, do
hereby depose and say that:

1. I am the lawful owner of a KAPA Form.

2. I inadvertently misplaced said item and despite earnest efforts to locate

the same, it could no longer be found;

3. I now declare it lost and beyond recovery; and

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

for all intents and purposes this may legally serve.

IN WITNESS WHEREOF, I have hereunto affixed my signature this 23rd

day of October 2018 at Glan, Sarangani Province, Philippines.

CHARISSA MAE L. TABANAO

Affiant
VIN: 6303-0286F-C2592CLT20000

SUBSCRIBED AND SWORN to before me this 23rd day of October 2018

at Glan, Sarangani Province, Philippines, affiant exhibited to me her valid
identification card indicated below her name.

DOC. NO.____________;
PAGE NO.____________;
BOOK NO.____________;
SERIES OF 2018.