Republic of the Philippines)

Province of Cagayan )S.S.

City of Tuguegarao )

AFFIDAVIT OF LOSS

I, AVELINA VISALDA PANOPIO, of legal age, Filipino, Widow , and a resident of BLK 2 LOT 10
Sunshine Valley Homes Pengue,Tuguegarao City, Cagayan, Philippines, after having been duly
sworn in accordance with law, hereby depose and state;

1. I was issued a copy of Original Policy Contract by the Government Service Insurance
System(GSIS) Tuguegarao City, Cagayan,;

2. That recently I had tried to look for the said Policy Contract but the same could not be
found;

3. That despite diligent search and efforts to locate the said document , I could not find the
same such that I know believe that it is now lost beyond recovery;

4. That I am submitting this affidavit of loss in support with my claim for my retirement.

5. As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing.

IN WITNESS WHEREOF, I have hereunto set my hand this ________ day of ______ at
Tuguegarao City, Cagayan.

AVELINA VISALDA PANOPIO

Affiant

SUBSCRIBED AND SWORN to before me, this ____ day of ______________, 20___ in
Tuguegarao City, with affiant exhibiting her Unified Mutli-Purpose ID No. CRN-006-0024-5852-B
as competent proof of identity.

NOTARY PUBLIC

Doc. No. : ________;

Page No. : ________;
Book No. : ________;
Series of 20_______.
Republic of the Philippines)
Province of Cagayan )S.S.
City of Tuguegarao )

AFFIDAVIT OF LOSS

I, ________________________, of legal age, Filipino, married, and a resident of

________________________, Philippines, after having been duly sworn in accordance with law,
hereby depose and state;

1. That I am the registered owner of a certain motor vehicle, which is more particularly
describe as follows:
Make:
Series:
Type of body:
Motor No.:
Chassis No.:
Year Model:
Color:
Plate No.:
2. That as a registered owner, I was issued a Certificate of Registration (C.R.) and an
Original Receipt (O.R.) for my registration for the year ____ by the Land Transportation
Office of Tuguegarao City, Cagayan, Philippines.
3. That when I was about to register the said motor vehicle for the year ___, I could no
longer find said Certificate of Registration and Official Receipt of the said motor vehicle.
4. That despite diligent search and efforts to locate the said documents, I could no longer
find the same such that I believe that they are now lost beyond recovery.
5. As such, I am executing the Affidavit of Loss to attest to the truth of the foregoing and to
support my application for the issuance of new Certificate of Registration and Original
Receipt, in lieu of the ones that were lost.

IN WITNESS WHEREOF, I have hereunto set my hand this 16 th day of April 2018 in the City of
Tuguegarao, Province of Cagayan, Philippines.

______________________
Affiant

SUBSCRIBED AND SWORN to before me, this 16th day of April, 2018 in Tuguegarao City,
with affiant exhibiting his Government Issued I.D. No. ____________, issued at
___________________________ on __________________.

NOTARY PUBLIC

Doc. No. : ______;

Page No. : ______;
Book No. : ______;
Series of 2018.
Republic of the Philippines)
Province of Cagayan )S.S.
City of Tuguegarao )

AFFIDAVIT OF LOSS

I, CHONA S. LIM, of legal age, Filipino, single, and a resident of #13 Sugar Cane Road,
Plantation Villas Subdivision, Caggay, Tuguegarao City, Cagayan, Philippines, after having been
duly sworn in accordance with law, hereby depose and state;

1. That I am a duly-licensed driver in accordance with pertinent Land Transportation laws,

rules and regulations, and was issued a corresponding Driver’s License which is valid
until August 19, 2019;

2. Sometime in March 2018. said driver’s license was misplaced and got lost;

3. Efforts were exerted to locate said driver’s license, but in spite of diligent search, it could
not be found and the same is now beyond recovery;

4. Said Driver’s License has not been confiscated by the LTO, Police or other Traffic
Enforcers for any traffic violation;

5. As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing and to
support my application for the issuance of new Non- Professional Driver’s License, in
lieu of the one that were lost.

IN WITNESS WHEREOF, I have hereunto set my hand this _______ day of _________ in the
City of Tuguegarao, Province of Cagayan, Philippines.

CHONA S. LIM
Affiant

SUBSCRIBED AND SWORN to before me, this ________ day of _______, 2018 in
Tuguegarao City, with affiant exhibiting his Government Issued I.D. No. PRC No. 0199844,
issued at Tuguegarao City, Cagayan on August 19, 2017.

Doc. No. : ______;

Page No. : ______;
Book No. : ______;
Series of 2018.