Republic of the Philippines

City of Iloilo ) S.S.

AFFIDAVIT OF LOSS

I, MICHAEL FRANCO PACIT, of legal age, Filipino, single and a

resident of Commission Civil Streetm Jaro, Iloilo City, after having been duly
sworn to in accordance with law, hereby depose and say:

1. That I am the owner of a pag – ibig loyalty card.

2. That the said loyalty card was last seen in my room.
3. That the said loyalty card was last seen by me last August 28, 2018.
4. That the said loyalty card was lost for all intents and purposes and
cannot be located despite all efforts exerted to locate the same.
5. That I execute this affidavit in order to request for a new pag – ibig
loyalty card.
6. That I am executing this affidavit to attest to the truth to all the above
facts.

IN WITNESS HEREOF, I have hereunto signed my name below this

30th day of August, 2018 at Iloilo City, Philippines.

MICHAEL FRANCO PACIT

Affiant
 SUBSCRIBED AND SWORN TO BEFORE ME this 30th day of August,
2018, affiant exhibited to me his unified multipurpose identification card with
card no. 0111-4034996.

Doc No.82
Page No. 17
Book No. 1
Series of 2018