Republic of the Philippines)
Province of Cagayan )
Tuguegarao City )
AFFIDAVIT OF LOSS
I, _JERRY N. BALAGAN_, of legal age, married, Filipino and a resident of
503 Dangaran, St. Buntun, Tuguegarao City, Cagayan__ after having been duly sworn
to in accordance with law, do hereby depose and say that:
1. I am a bonafide holder of Land Bank of the Philippines ATM Card SA Number
0306-0171-00 issued by the Land Bank of the Philippines, Tuguegarao City,
Cagayan;
2. On March 29, 2019, I inadvertently loss my Land Bank of the Philippines ATM
Card.
3. After diligent search, my Land Bank of the Philippines ATM Card nowhere to be
found anymore.
4. I am executing this affidavit to attest to the truthfulness and veracity of the
foregoing facts and circumstances and for purposes of reporting the loss of my
Policy.
IN TRUTH WHEREOF, I have hereunto set my hand and affix my signature this
15th day of October, 2019 at the place first above written.
JERRY N. BALAGAN
Affiant
SUBSCRIBED and SWORN to before me this _____day of
_________________ at Tuguegarao City, Cagayan.
_____________________
Notary Public
Doc. No. ______________
Page No. _______________
Book No ______________
Series of 2019 __________
Republic of the Philippines)
Province of Cagayan )
Tuguegarao City )
AFFIDAVIT OF LOSS
I, _ALEJANDRO S. ABELLA_, of legal age, married, Filipino and a resident of
_32 Libertad St., Centro Southwest, Solana, Cagayan__ after having been duly sworn to
in accordance with law, do hereby depose and say that:
5. I am a bonafide holder of Policy Contract Number CM00004133877 issued by
the Government Service Insurance System, Tuguegarao City, Cagayan;
6. On September 17, 2018, I inadvertently loss my Policy Contract.
7. After diligent search, my Policy Contract nowhere to be found anymore.
8. I am executing this affidavit to attest to the truthfulness and veracity of the
foregoing facts and circumstances and for purposes of reporting the loss of my
Policy.
IN TRUTH WHEREOF, I have hereunto set my hand and affix my signature this
23rd day of October, 2018 at the place first above written.
ALEJANDRO S. ABELLA
Affiant
SUBSCRIBED and SWORN to before me this ____day of _________________
at Tuguegarao City, Cagayan.
_____________________
Notary Public
Doc. No. ______________
Page No. _______________
Book No ______________
Series of 2018 __________
Republic of the Philippines)
Province of Cagayan )
Tuguegarao City )
AFFIDAVIT OF LOSS
I, FERNANDO M. OLONAN, of legal age, married, Filipino and a resident of
Purok 4, San Manuel, Naguilian, Isabela after having been duly sworn to in accordance
with law, do hereby depose and say that:
9. I am a bonafide holder of Policy Contract Number CM00002478014 issued by
the Government Service Insurance System, Tuguegarao City, Cagayan;
10. On July 6, 2018, I inadvertently loss my Policy Contract.
11. After diligent search, my Policy Contract nowhere to be found anymore.
12. I am executing this affidavit to attest to the truthfulness and veracity of the
foregoing facts and circumstances and for purposes of reporting the loss of my
Policy.
IN TRUTH WHEREOF, I have hereunto set my hand and affix my signature this
9th day of July, 2018 at the place first above written.
FERNANDO M. OLONAN
Affiant
SUBSCRIBED and SWORN to before me this ____day of _________________
at Tuguegarao City, Cagayan.
_____________________
Notary Public
Doc. No. ______________
Page No. _______________
Book No ______________
Series of 2018 __________
Republic of the Philippines)
Province of Cagayan )
Tuguegarao City )
AFFIDAVIT OF LOSS
I, JAIME A. CASTILLEJOS, of legal age, married, Filipino and a resident of
Barangay Kayvaluganan, Basco, Batanes, after having been duly sworn to in accordance
with law, do hereby depose and say that:
13. I am a bonafide holder of PRC License card _36938__ issued by the
Professional Regulatory Commission, Manila.
14. On June 13, 2017, I inadvertently loss my PRC License card.
15. After diligent search, my PRC License card nowhere to be found anymore.
16. I am executing this affidavit to attest to the truthfulness and veracity of the
foregoing facts and circumstances and for purposes of reporting the loss of my
PRC License card to the Professional Regulatory Commission and requesting the
said office to grant me a new PRC License card in lieu of the loss one.
IN TRUTH WHEREOF, I have hereunto set my hand and affix my signature this
19th day of June, 2017 at the place first above written.
JAIME A. CASTILLEJOS
Affiant
SUBSCRIBED and SWORN to before me this __19th__day of June 2017 at
Tuguegarao City, Cagayan.
_____________________
Notary Public
Doc. No. ______________
Page No. _______________
Book No ______________
Series of 2017 __________
Republic of the Philippines)
Province of Cagayan )
Tuguegarao City )
AFFIDAVIT OF LOSS
I, GILBERT P. UBANDO, of legal age, single, Filipino and a resident of
Barangay Capo, Ilagan, Isabela, after having been duly sworn to in accordance with law,
do hereby depose and say that:
17. I am a bonafide holder of ATM card 3707-0595-58 issued by the Land Bank of
Philippines, Carig Tuguegarao Branch, Tuguegarao City, Cagayan.
18. On January 24, 2017, I inadvertently loss my LBP ATM card.
19. After diligent search, my LBP ATM card was nowhere to be found anymore.
20. I am executing this affidavit to attest to the truthfulness and veracity of the
foregoing facts and circumstances and for purposes of reporting the loss of my
LBP ATM card to the Land Bank of Philippines and requesting the said office to
grant me a new LBP ATM card in lieu of the loss one.
IN TRUTH WHEREOF, I have hereunto set my hand and affix my signature this
25th day of January, 2017 at the place first above written.
GILBERT P. UBANDO
Affiant
SUBSCRIBED and SWORN to before me this _________day of January 2017 at
Tuguegarao City, Cagayan.
_____________________
Notary Public
Doc. No.
Page No.
Book No.
Series of 2017
Republic of the Philippines)
Province of Cagayan )
Tuguegarao City )
AFFIDAVIT OF LOSS
I, _____________________, of legal age, married, Filipino and a resident of
_________________________________ after having been duly sworn to in accordance
with law, do hereby depose and say that:
1. I am the wife of the late Mr. Roberto R. Agcaoili an Policy Contract No. CM-
4111759 issued by the Government Service Insurance System, Tuguegarao
Branch, Carig Sur, Tuguegarao City, Cagayan.
2. I inadvertently misplaced and lost the said original Policy Contract No. CM-
4111759.
3. After diligent search, the Policy Contract No. CM-4111759 was nowhere to be
found anymore.
4. I am executing this affidavit to attest to the truth and veracity of the foregoing
facts and circumstances and for purposes of reporting the loss of the Policy
Contract No. CM-4111759 to the Government Service Insurance System,
Tuguegarao City branch office and requesting the said office the one lost.
IN TRUTH WHEREOF, I have hereunto set my hand and affix my signature this
6th day of May, 2016 at the place first above written.
LUCY L. AGCAOILI
Affiant
SUBSCRIBED and SWORN to before me this 6th day of May, 2016 at
Tuguegarao City, Cagayan.
_______________________
Notary Public
Doc. No.
Page No.
Book No.
Series of 2016
Republic of the Philippines)
Province of Cagayan )
Tuguegarao City )
AFFIDAVIT OF LOSS
I, MRS. NERIE D. BUENO, of legal age, married, Filipino and a resident of 96 M.
Roxas Road, Lower Brookside, Baguio City after having been duly sworn to in
accordance with law, do hereby depose and say that:
5. I am the wife of the late Mr. Roberto R. Agcaoili an Policy Contract No. CM-
4111759 issued by the Government Service Insurance System, Tuguegarao
Branch, Carig Sur, Tuguegarao City, Cagayan.
6. I inadvertently misplaced and lost the said original Policy Contract No. CM-
4111759.
7. After diligent search, the Policy Contract No. CM-4111759 was nowhere to be
found anymore.
8. I am executing this affidavit to attest to the truth and veracity of the foregoing
facts and circumstances and for purposes of reporting the loss of the Policy
Contract No. CM-4111759 to the Government Service Insurance System,
Tuguegarao City branch office and requesting the said office the one lost.
IN TRUTH WHEREOF, I have hereunto set my hand and affix my signature this
6th day of May, 2016 at the place first above written.
LUCY L. AGCAOILI
Affiant
SUBSCRIBED and SWORN to before me this 6th day of May, 2016 at
Tuguegarao City, Cagayan.
_______________________
Notary Public
Doc. No.
Page No.
Book No.
Series of 2016
Republic of the Philippines)
Province of Cagayan )
Tuguegarao City )
AFFIDAVIT OF LOSS
I, MRS. LUCY L. AGCAOILI, of legal age, widower, Filipino and a resident of
Gattaran, Cagayan after having been duly sworn to in accordance with law, do hereby
depose and say that:
9. I am the wife of the late Mr. Roberto R. Agcaoili an Policy Contract No. CM-
4111759 issued by the Government Service Insurance System, Tuguegarao
Branch, Carig Sur, Tuguegarao City, Cagayan.
10. I inadvertently misplaced and lost the said original Policy Contract No. CM-
4111759.
11. After diligent search, the Policy Contract No. CM-4111759 was nowhere to be
found anymore.
12. I am executing this affidavit to attest to the truth and veracity of the foregoing
facts and circumstances and for purposes of reporting the loss of the Policy
Contract No. CM-4111759 to the Government Service Insurance System,
Tuguegarao City branch office and requesting the said office the one lost.
IN TRUTH WHEREOF, I have hereunto set my hand and affix my signature this
6th day of May, 2016 at the place first above written.
LUCY L. AGCAOILI
Affiant
SUBSCRIBED and SWORN to before me this 6th day of May, 2016 at
Tuguegarao City, Cagayan.
_______________________
Notary Public
Doc. No.
Page No.
Book No.
Series of 2016
Republic of the Philippines)
Province of Cagayan )
Tuguegarao City )
AFFIDAVIT OF LOSS
I, NERIE D. BUENO, of legal age, married, Filipino and a resident of 96 M. Roxas
Road, Lower Brookside, Baguio City, after having been duly sworn to in accordance with
law, do hereby depose and say that:
21. I am a bonafide holder of UMID card issued by the Union Bank, Baguio City.
22. On April 15, 2016, I inadvertently misplaced my UMID card.
23. After diligent search, my UMID card was nowhere to be found anymore.
24. I am executing this affidavit to attest to the truthfulness and veracity of the
foregoing facts and circumstances and for purposes of reporting the loss of my
UMID card to the Union Bank and requesting the said office to grant me a new
UMID card in lieu of the misplaced one.
IN TRUTH WHEREOF, I have hereunto set my hand and affix my signature this
9th day of June, 2016 at the place first above written.
NERIE D. BUENO
Affiant
SUBSCRIBED and SWORN to before me this _________day of June 2016 at
Tuguegarao City, Cagayan.
_____________________
Notary Public
Doc. No.
Page No.
Book No.
Series of 2009
