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Affidavit of Loss - Claim Stub

1) Dechun Li, a Chinese citizen residing in Tagbilaran City, Philippines, lost his claim stub for a visa extension that was issued by the Bureau of Immigration, Bohol Field Office on February 14, 2019 despite searching diligently. 2) Dechun Li requests that the Bureau of Immigration issue a replacement for his lost visa extension claim stub. 3) Dechun Li agrees to indemnify the Bureau of Immigration for any losses incurred by issuing a replacement claim stub.

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Agang Molina Columnas
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574 views1 page

Affidavit of Loss - Claim Stub

1) Dechun Li, a Chinese citizen residing in Tagbilaran City, Philippines, lost his claim stub for a visa extension that was issued by the Bureau of Immigration, Bohol Field Office on February 14, 2019 despite searching diligently. 2) Dechun Li requests that the Bureau of Immigration issue a replacement for his lost visa extension claim stub. 3) Dechun Li agrees to indemnify the Bureau of Immigration for any losses incurred by issuing a replacement claim stub.

Uploaded by

Agang Molina Columnas
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Republic of the Philippines)

City of Tagbilaran           ) S.S.

AFFIDAVIT OF LOSS

I, DECHUN LI, Chinese, of legal age, single, and with residence at 15


Salesi Road, Namadi, Heights, after being duly sworn to in accordance with law,
hereby depose and state:

1. That I am a holder/owner/possessor of a claim stub for my Visa


Extension which was issued by the Bureau of Immigration, Bohol
Field Office;

2. That on about February 14, 2019, the claim stub, was lost and its
whereabouts cannot be ascertained despite due and diligent search
made and undertaken such that I now believe that the same is lost
beyond recovery;

3. That I now request the Bureau of Immigration to issue an extension


of my visa;

4. That I covenant to indemnify the Bureau of Immigration for any loss


and damage it may incur by reason of its issuance or replacement;

5. That I am executing this affidavit to attest to the veracity of the


above-stated facts or any other legal purpose which this affidavit
may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this 18 th day of


February 2019 at Tagbilaran City, Philippines.

DECHUN LI
Affiant
DL No. 914143
Issued by: Republic of Fiji

SUBSCRIBED AND SWORN TO BEFORE ME this 18 th day of February


2019 affiant personally presented to me his competent and valid proof of his
identity.

Doc No. _____;


Page No. _____;
Book No. _____;
Series of 2019.

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