Republic of the Philippines. . . . . .

)
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ARIEL E. PATROCINIO, of legal age, Filipino, single, with address of Isis, Polanco, Zamboanga del
Norte after having been duly sworn in accordance with law, hereby depose and state:

That I was a holder and possessor of a Globe/TM SimCard with number 09069172974.

That recently, I found out that the simcard was nowhere to be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said simcard.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2024, at
Dipolog City.

ARIEL E. PATROCINIO
(Affiant)
Valid ID#___________
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2024
 LANDBANK OF THE PHILIPPINES
Manila, Philippines

AFFIVIDAVIT OF LOSS WITH DEED OF INDEMNITY

(Passbook/ATM Card/CTD/Manager’s Check/FX Demand Draft/Gift Check)

REPUBLIC OF THE PHILIPPINES

CITY MUNICIPALITY OF DIPOLOG) S.S

I, JAYCEL S. RIVERO, of legal age, single/married and residing at East Poblacion, Rizal,
Zamboanga del Norte, Philippines, after being duly sworn in accordance with law, hereby
depose and state that:

I am/We are the holder of ATM Savings Account/Current Account with ATM Access/
Peso EASY Check with ATM Access under Account No. __________________/ATM Card
No,______________with an outstanding balance of
₱ as of .

Sometime on or about November 25, 2024, the above-mentioned Passbook/ATM Card/CTD/Manager’s

Check/FX Demand Draft/Gift Check was lost in my possession under the following
circumstances:

I noticed that aforementioned ATM card was lost from my usual place of safekeeping

Diligent efforts to search for the above-mentioned document were made and exhausted but all of which
resulted in vain;

In view thereof, Landbank of the Philippines is hereby requested to issue a replacement for the lost
Passbook/ATM Card/CTD/Manager’s Check/FX Demand Draft/Gift Check and I/We bind myself/ourselves to
surrender the lost Passbook/ATMCard/CTD/Manager’s Check/FX Demand Draft/Gift Check in the event the
same is found and/or located.

In consideration of the foregoing, I/We hereby bind myself/ourselves to indemnity the Landbank of the
Philippines for any loss or damage it may incur from any and all claims as well as costs and expenses in
connection with the issuance of the new Passbook/ATM Card/CTD/Manager’s Checks/FX Demand Draft/Gift
Check covering the balance of ₱/$ , of the above-mentioned lost Passbook/ATM Card/CTD/Manager’s
Check/FX Demand Draft/Gift Check.

I/We hereby attest to the truth of the foregoing and I/We am/are willing to testify before any court of justice
to substantiate the truth of each and all of the aforesaid facts.

IN WITNESS WHEREOF, the undersigned signed these presents in Dipolog City, Philippines,
on this day of ,2024.

JAYCEL S. RIVERO

Name and Signature/s of Affiant/s Name and Signature/s of Affiant/s

SUBSCRIBED AND SWORN to before me in , Philippines, on this day of

, 20 , Affiant/s exhibiting to me his/her/their government issued ID _________ Issued
on __________ in __________, Philippines.

NOTARY PUBLIC
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, MELVIN T. HAMOY, of legal age, Filipino, married, with address of 086 Padre Zamora St Ext.,
Riverside, Estaka.,Dipolog City, Zamboanga del Norte after having been duly sworn in accordance
with law, hereby depose and state:

That I was a holder and possessor of METROBANK ATM CARD issued by METROBANK, CHINABANK
ATM CARD issued by CHINABANK, PAG-IBIG ID CARD issued by PAG-IBIG, LANDBANK ATM CARD
issued by LANDBANK, DRIVERS LICENSE issued by LTO, PRC LICENSE issued by PRC, MLHUILLIER
RECEIPT issued by MLHUILLIER and CBS ATM CARD issued by CBS.

That recently, I found out that the afore-mentioned cards and documents were nowhere to be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the saidMETROBANK ATM CARD issued by METROBANK,
CHINABANK ATM CARD issued by CHINABANK, PAG-IBIG ID CARD issued by PAG-IBIG, LANDBANK
ATM CARD issued by LANDBANK, DRIVERS LICENSE issued by LTO, PRC LICENSE issued by PRC,
MLHUILLIER RECEIPT issued by MLHUILLIER and CBS ATM CARD issued by CBS.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2024, at
Dipolog City.

MELVIN T. HAMOY
(Affiant)
Drivers License#J01-03-041532
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2024
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, EBENEZER D. DIMAGNAONG, of legal age, Filipino, married, with address at Rizal Ave, Cawa Cawa,
Dapitan City, Zamboanga del Norte after having been duly sworn in accordance with law, hereby
depose and state:

That I was a possessor of Claim Slip with Number 27892 issued in the name of Magangon E/S issued
by Dipolog Savers Mart on November 9, 2024.

That recently, I found out that the said claim was not inside my bag, but it was lost and could not be
found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said Claim Slip.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2024, at
Dipolog City.

EBENEZER D. DIMAGNAONG
(Affiant)
PRC ID#0525684
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2024
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, JOYCE P. MARTINEZ, of legal age, Filipino, with office address of DOnamp’s Bakeshop, Osmena
St.,Dipolog City, Zamboanga del Norte after having been duly sworn in accordance with law, hereby
depose and state:

That I was possessor of Certificate of Registration as well as unused receipts of Donamp’s Bakeshop,
located at Osmena st., Dipolog City issued by the Bureau of Internal Revenue.

That recently, while I was trying to arrange several office documents and locating the said BIR
Certificate of Registration and unused receipts, but it was lost and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said Original Copy of Certificate of Registration and unused
receipts.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2024, at
Dipolog City.

JOYCE P. MARTINEZ
(Affiant)
Valid iD#___________
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2024

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

SWORN STATEMENT

I, PRINCESS MAE D. LADERA, of legal age, Filipino, single, with address of Dipolog City,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and
state:
That I am the child of Roland B. Ladera and Ma. Tessie D. Ladera.

That I execute this affidavit expressing support to my father Roland B. Ladera regarding the
complaint filed by my mother Ma. Tessie D. Ladera at the DILG-Bureau of Fire Protection;

That I attest that my father has always been supporting us financially eversince he and my
mother separated from each other;

That it was my father who supported me and my brother Kimberly to school that is why we are
already professionals now and we have been employed by the government;

That since my shool years in elementary my father had been supportive with us financially and I
even lived with my father and my grandmother Lourdes(aunt of my father). That then in high
school I lived with my mother but my father had been supporting us financially. That I then
learned that my father sent us P4,000.00 monthly but my mother only gave P500.00 for me and
Kimberly. Aside from the P4,000.00 cash, my father also paid the electric, water utilities, rice
and our groceries monthly. That during college years I was a recipient of scholarship so I had
not paid my tuition fees but it was my father who supported my other school expenses and I
lived with my father because my mother could not support me. Despite my transfer to my
father, my father continued supporting my mother and brother until my brother graduated from
school. That during my board examination review, it was my father who supported me
financially and emotionally.

That in addition, my mother was living at their conjugal house but she abandoned it. It was my
father who caused the repair of the house and reconnected electrical and water utilities so I have
been living in the house.

That my father did not ever abandon us, my father did not left us and did not ever fail to feed
us. Although the marital relations between my parents turned sour but I always love and support
both of my parents. It is just disheartening that my mother continues to harass my father
although they have been living out from each other’s lives for more than a decade now.

That I know my mother has her own life now as well as my father but it is not fair with my
father to be harassed continuously by my mother;

That I and brother are not anymore dependent with my father because we have been gainfully
employed yet he would sometimes extend to us assistance and even gave us properties so that
we would not ask anymore from him.

That I attest that all of the complaint of my mother before the Bureau of Fire Protection
including court cases are just baseless and there is no truth to it, she just wants to drain off
money from him.

That I plea that the complaint of my mother be dismissed for being lack of merit and it is just a
mere harassment against our father.

As such, I am executing this statement to attest to the truth of the foregoing statements.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of November
2024, at Dipolog City.

PRINCESS MAE D. LADERA

 (Affiant)
PRC ID#0145129
Valid until 4-16-2026
With photo

SUBSCRIBED AND SWORN to before me this ___ day of November 2024, at Dipolog City
showing his/her document of identity as indicated above.

Doc. No.

Page No.

Book No.

Series of 2024
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ALICIA EDNA BEJER, of legal age, Filipino, single, a resident of New Tambo,
Katipunan, Zamboanga del Norte after having been duly sworn in accordance
with law, hereby depose and state:

That I was a holder and possessor of the technical descriptions of Approved

Subdivision Plan PSD-09-053190 for parcel of land Lot 407-B-2, situated at Tambo,
Katipunan, Zamboanga del Norte.

That recently while I was checking my file containing the said documents so that I
could process titling over said land, I found out that the technical description
documents for Lot 407-B-2-D and Lot 407-B-2-G were lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it
as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
statements and for the purpose of attesting to the loss of the said technical
descriptions documents and request for replacement of the same.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2024, at Dipolog City.

ALICIA EDNA BEJER

(Affiant)
Valid ID#____________

With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at Dipolog
City.
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, JHAN NIAN J. MI-OT, of legal age, Filipino, single, a resident of Kanim,

Sibutad Zamboanga del Norte after having been duly sworn in accordance
with law, hereby depose and state:

That I was a holder and possessor of a PRC license with number 0034616
issued by PRC, Drivers License issued by LTO and National ID issued by PSA;

That recently, I discovered that my said licenses/cards were lost, and could
not be found;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost;

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

foregoing statements and for the purpose of attesting to the loss of the said
licenses/cards and thereafter requesting replacement of the same.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2024, at Dipolog City.

JHAN NIAN J. MI-OT

(Affiant)

Philhealth ID#14-252390377-1

With photo
SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024 by
above-named person showing her document of identity as shown above, at
Dipolog City.

Doc. No.

Page No.

Book No.

Series of 2024

LANDBANK OF THE PHILIPPINES

Manila, Philippines

AFFIVIDAVIT OF LOSS WITH DEED OF INDEMNITY

(Passbook/ATM Card/CTD/Manager’s Check/FX Demand Draft/Gift Check)

REPUBLIC OF THE PHILIPPINES

CITY MUNICIPALITY OF DIPOLOG) S.S

I, JHAN NIAN J. MI-OT, of legal age, single/married and residing at Kanim, Sibutad, Zamboanga
del Norte, Philippines, after being duly sworn in accordance with law, hereby depose and state
that:

I am/We are the holder of ATM Savings Account/Current Account with ATM Access/
Peso EASY Check with ATM Access under Account No. 5217244945/ATM Card
No,______________with an outstanding balance of
₱ as of .

Sometime on or about November 14, 2024, the above-mentioned Passbook/ATM Card/CTD/Manager’s

Check/FX Demand Draft/Gift Check was lost in my possession under the following
circumstances:

I left ait at my apartment but upon my return the card was gone

Diligent efforts to search for the above-mentioned document were made and exhausted but all of which
resulted in vain;

In view thereof, Landbank of the Philippines is hereby requested to issue a replacement for the lost
Passbook/ATM Card/CTD/Manager’s Check/FX Demand Draft/Gift Check and I/We bind myself/ourselves to
surrender the lost Passbook/ATMCard/CTD/Manager’s Check/FX Demand Draft/Gift Check in the event the
same is found and/or located.

In consideration of the foregoing, I/We hereby bind myself/ourselves to indemnity the Landbank of the
Philippines for any loss or damage it may incur from any and all claims as well as costs and expenses in
connection with the issuance of the new Passbook/ATM Card/CTD/Manager’s Checks/FX Demand Draft/Gift
Check covering the balance of ₱/$ , of the above-mentioned lost Passbook/ATM Card/CTD/Manager’s
Check/FX Demand Draft/Gift Check.
 I/We hereby attest to the truth of the foregoing and I/We am/are willing to testify before any court of justice
to substantiate the truth of each and all of the aforesaid facts.

IN WITNESS WHEREOF, the undersigned signed these presents in Dipolog City, Philippines,
on this day of ,2024.

JHAN NIAN J. MI-OT

Name and Signature/s of Affiant/s Name and Signature/s of Affiant/s

SUBSCRIBED AND SWORN to before me in , Philippines, on this day of

, 20 , Affiant/s exhibiting to me his/her/their government issued ID Philhealth ID
No.14-252390377-1 Issued on __________ in __________, Philippines.

NOTARY PUBLIC

LANDBANK OF THE PHILIPPINES

Manila, Philippines

AFFIVIDAVIT OF LOSS WITH DEED OF INDEMNITY

(Passbook/ATM Card/CTD/Manager’s Check/FX Demand Draft/Gift Check)

REPUBLIC OF THE PHILIPPINES

CITY MUNICIPALITY OF DIPOLOG) S.S

I, ERLINDA M. ORILLA, of legal age, single/married and residing at Villa C. Sudiacal, Liloy,
Zamboanga del Norte, Philippines, after being duly sworn in accordance with law, hereby
depose and state that:

I am/We are the holder of ATM Savings Account/Current Account with ATM Access/
Peso EASY Check with ATM Access under Account No. 5177120237/ATM Card
No,4748445171120500with an outstanding balance of
₱ as of .

Sometime on or about November 14, 2024, the above-mentioned Passbook/ATM Card/CTD/Manager’s

Check/FX Demand Draft/Gift Check was lost in my possession under the following
circumstances:

My spouse lost it in his possession after withdrawing from ATM machine

Diligent efforts to search for the above-mentioned document were made and exhausted but all of which
resulted in vain;

In view thereof, Landbank of the Philippines is hereby requested to issue a replacement for the lost
Passbook/ATM Card/CTD/Manager’s Check/FX Demand Draft/Gift Check and I/We bind myself/ourselves to
surrender the lost Passbook/ATMCard/CTD/Manager’s Check/FX Demand Draft/Gift Check in the event the
same is found and/or located.

In consideration of the foregoing, I/We hereby bind myself/ourselves to indemnity the Landbank of the
Philippines for any loss or damage it may incur from any and all claims as well as costs and expenses in
connection with the issuance of the new Passbook/ATM Card/CTD/Manager’s Checks/FX Demand Draft/Gift
Check covering the balance of ₱/$ , of the above-mentioned lost Passbook/ATM Card/CTD/Manager’s
 Check/FX Demand Draft/Gift Check.

I/We hereby attest to the truth of the foregoing and I/We am/are willing to testify before any court of justice
to substantiate the truth of each and all of the aforesaid facts.

IN WITNESS WHEREOF, the undersigned signed these presents in Dipolog City, Philippines,
on this day of ,2024.

ERLINDA M. ORILLA

Name and Signature/s of Affiant/s Name and Signature/s of Affiant/s

SUBSCRIBED AND SWORN to before me in , Philippines, on this day of

, 20 , Affiant/s exhibiting to me his/her/their government issued ID OSCA, ID
No.9207 Issued on July 2, 2017 in Dipolog City, Philippines.

NOTARY PUBLIC

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ERLINDA M. ORILLA, of legal age, Filipino, single, a resident of National

Highway Lawaan, Dawo, Dapitan City, Zamboanga del Norte after having
been duly sworn in accordance with law, hereby depose and state:

That I was a holder and possessor of a Globe Sim card with number
639453645517;

That recently, I discovered that my said simcard was lost, and could not be
found;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost;

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

foregoing statements and for the purpose of attesting to the loss of the said
sim card and thereafter requesting replacement of the same.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2024, at Dipolog City.

SHAMIRA MAY E. ADASA

 (Affiant)

PRC ID#1449991

With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024 by

above-named person showing her document of identity as shown above, at
Dipolog City.

Doc. No.

Page No.

Book No.

Series of 2024

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, GLESSEL G. DUMALO-AN, Filipino, of legal age, single , and a resident of

Bandera, Polanco, Zamboanga del Norte after having been duly sworn in
accordance with law, hereby depose and state:

That I was a holder and possessor of receipt with number 132101396-2024-

00983 dated 9 September 2024 issued by MLhuillier for pawned jewelry
described as Necklace YG in the amount of P5,000.00;

That recently, I found out that my receipt was lost, I tried to locate the
receipts but it was really lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
receipt.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2024, at Dipolog City.
 GLESSEL G. DUMALO-AN
(Affiant)
Phil.ID#3856-0752-6318-6742
With phot

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at

Dipolog City.

Doc. No.__
Page No.__
Book No.__
Series of 2024

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, EDIONA D. ICALINA, of legal age, Filipino, widow, a resident of Purok

Parpagayo, Minaog, Dipolog City, Zamboanga del Norte after having been
duly sworn in accordance with law, hereby depose and state:

That I was a holder and possessor of a Philippine Passport issued by the

Department of Foreign Affairs;

That recently, I discovered that my passport was lost;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
passport.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2024, at Dipolog City.
 EDIONA D. ICALINA
(Affiant)
OSCA ID#18348-Dipolog City
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at

Dipolog City showing his/her document of identity as indicated above.

Doc. No.___

Page No.___

Book No.___

Series of 2024

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS
I, JOVITA L. ALFEREZ, of legal age, Filipino, married, a resident of Estaka,
Dipolog City, Zamboanga del Norte, after having been duly sworn in
accordance with law, hereby depose and state:

That I was a holder and possessor of an Passbook with Account

No.121851057802 issued by Producers Bank;

That recently, while I was trying to look for the said Passbook from where I
kept it, I found out that the Passbook was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost;

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

foregoing statements and for the purpose of attesting to the loss of the said
Passbook.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2024, at Dipolog City.

JOVITA L. ALFEREZ
(Affiant)
PRC ID#1167560
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at

Dipolog City showing his/her document of identity as indicated above.

Doc No. _____

Page No. _____
Book No. ____
Series of 2024

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS
I, KRYSTTELE BASTASA FLORES, of legal age, Filipino, married, a resident of
One Heart, Sta. Filomena, Dipolog City, Zamboanga del Norte after having
been duly sworn in accordance with law, hereby depose and state:

That I was a holder and possessor of a Philippine Passport with Number

P1079554B issued by the Department of Foreign Affairs;

That on October 17, 2024, I discovered that my passport was lost;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
passport.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2024, at Dipolog City.

KRYSTTELE BASTASA FLORES

(Affiant)
Phil ID#5465-3164-5820-9684
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at

Dipolog City showing his/her document of identity as indicated above.

Doc. No.___

Page No.___

Book No.___

Series of 2024

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS
I, ROSENIE S. HIMAYA, of legal age, Filipino, married, a resident of Galas,
Dipolog City, Zamboanga del Norte after having been duly sworn in
accordance with law, hereby depose and state:

That I was a holder and possessor of a TM Sim card with number

639525024604;

That recently, I discovered that my said simcard was lost, and could not be
found;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost;

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

foregoing statements and for the purpose of attesting to the loss of the said
sim card and thereafter requesting replacement of the same.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2024, at Dipolog City.

ROSENIE S. HIMAYA

(Affiant)

Passport No. P3045511B

With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024 by

above-named person showing her document of identity as shown above, at
Dipolog City.

Doc. No.

Page No.

Book No.

Series of 2024

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x
 AFFIDAVIT OF LOSS

I, JOVILEO R. PONTIOSO, of legal age, Filipino, single, a resident of

Relocation Site, Olingan, Dipolog City, Zamboanga del Norte after having
been duly sworn in accordance with law, hereby depose and state:

That I was a holder and possessor of a UnionBank Automated Teller

Machine(ATM) card with No.1096 7179 4048;

That recently, I discovered that my ATM card was lost;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
ATM card.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2024, at Dipolog City.

JOVILEO R. PONTIOSO
(Affiant)
Drivers License No.J01-16-002871
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at

Dipolog City showing his/her document of identity as indicated above.

Doc. No.___

Page No.___

Book No.___

Series of 2024
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I:ROMUALDO A. SUMOGBA, of legal age, Filipino, married, a resident of

Sinuyak,Katipunan, Dipolog City, Zamboanga del Norte after having been
duly sworn in accordance with law, hereby depose and state:

That I was a holder and possessor of Official Receipt(OR) and Certificate of

Registration(CR) of my vehicle with Plate No.JA 82073 , Chassis Number
PA040C000F0285693, Engine Number 40C-243918 Yamaha Mio Sporty 40Cs
issued by the Land Transportation Office(LTO);

That recently, my said certificate of registration and OR was lost;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
certificate of registration and OR.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2024, at Dipolog City.

ROMUALDO A. SUMOGBA

(Affiant)

Drivers License#j01-21-200180

With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at

Dipolog City showing her document of identification as indicated above.

Doc. No.

Page No.

Book No.

Series of 2024
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, DARIEL P. LINTASON, of legal age, Filipino, single, a resident of Minaog, Dipolog

City, Zamboanga del Norte after having been duly sworn in accordance with law,
hereby depose and state:

That I was a holder and possessor of the original copy of Motorized Tricycle
Operator’s Permit(MTOP) with number DPLG NO.2023-0684 valid until September
2024..

That recently while I was checking my file containing the said document so that I
could process the renewal, I found out that the document was lost, and could not
be found;

That despite effort to recover the same but it was naught. Hence, I considered it
as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
statements and for the purpose of attesting to the loss of the said MTOP.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2024, at Dipolog City.

DARIEL P. LINTASON
(Affiant)
Drivers License#J01-15-002885

With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at Dipolog
City.

Doc. No

Page No

Book No

Series of 2024
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, RICO M. PAGHACIAN, of legal age, Filipino, married, a resident of Lapayanbaja,

Polanco, Zamboanga del Norte after having been duly sworn in accordance with
law, hereby depose and state:

That I was a holder and possessor of the technical descriptions of Approved

Subdivision Plan PSD-09-054491 for parcel of land Lot 2705, Dip. Cad.85, situated
at Minaog, DIpolog City, Zamboanga del Norte.

That recently while I was checking my file containing the said documents so that I
could process titling over said land, I found out that the documents were lost, and
could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it
as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
statements and for the purpose of attesting to the loss of the said technical
descriptions documents and request for replacement of the same.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2024, at Dipolog City.

RICO M. PAGHACIAN
(Affiant)
SSS ID#33-5607689-5

With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at Dipolog
City.
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ROSEWEL C. LOYLOY, Filipino, of legal age, married , and a resident of

Estaka, Dipolog City, Zamboanga del Norte after having been duly sworn in
accordance with law, hereby depose and state:

That I was a holder and possessor of receipt with number 50304NP004232

dated 19 January 2024 issued by Cebuana Lhuillier for pawned jewelry
described as 1 DEF NECKLACE GOLD in the amount of P7,000.00;

That recently, I found out that my receipt was lost, I tried to locate the
receipts but it was really lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
receipt.

IN WITNESS WHEREOF, I have hereunto affixed my signature this 24 th day of

September 2024, at Dipolog City.

ROSEWEL C. LOYLOY
(Affiant)
UMID ID#CRN-0111-4343496-9
With phot
SUBSCRIBED AND SWORN to before me this 24th day of September 2024, at
Dipolog City.

Doc. No._____
Page No.__
Book No.___
Series of 2024

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, LUCICAR CIMAFRANCA BUHISAN, of legal age, Filipino,married, resident of Upper Dicayas, Dipolog
City, Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I was a holder and possessor of Official Receipts and other papers relative to my tuition fees for my studies
in Master of Arts in Education(MAEd) at the Medina College, Ozamiz City

That I recently looked for my said official receipts and papers but those were nowhere to be found;

That despite effort to recover the same but it was naught.

That I considered it as totally lost.

That I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for the purpose
of attesting to the loss of the said Official Receipts and papers.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ____th day of _____________ 2024, at
Dipolog City.
LUCICAR CIMAFRANCA BUHISAN

(Affiant)

PRC ID#0490875-Professional Teacher

With photo

SUBSCRIBED AND SWORN to before me this ___th day of _________ 2024, at Dipolog City.

DOC.NO. ______

PAGE NO.___

BOOK NO.___

SERIES OF 2024

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

SWORN STATEMENT

I, LUCICAR CIMAFRANCA BUHISAN, of legal age, Filipino,married, resident of Upper Dicayas, Dipolog
City, Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am an employee of Department of Education and an applicant for promotion;

That I have availed the professional career advancement by studying a master’s degree particularly Master of
Arts in Education(MAEd) at the Medina College, Ozamiz City;

That I hereby attest that I have secured Permit to Study for my said studies;

That during the tenure of my studies, there was no disruption or interference with my regular duties as teacher
during weekdays as my studies fell on weekends and during summer breaks until I have completed my
academic requirements towards MAEd in October 2018;

That I am executing this Sworn Statement to attest to the truth of the foregoing statements.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ____th day of _____________ 2024, at
Dipolog City.

LUCICAR CIMAFRANCA BUHISAN

(Affiant)

PRC ID#0490875-Professional Teacher

With photo

SUBSCRIBED AND SWORN to before me this ___th day of _________ 2024, at Dipolog City.

DOC.NO. ______

PAGE NO.___

BOOK NO.___

SERIES OF 2024

LANDBANK OF THE PHILIPPINES

Manila, Philippines

AFFIVIDAVIT OF LOSS WITH DEED OF INDEMNITY

(Passbook/ATM Card/CTD/Manager’s Check/FX Demand Draft/Gift Check)

REPUBLIC OF THE PHILIPPINES

CITY MUNICIPALITY OF ) S.S

I/WE , of legal age, single/married and residing at

, Philippines, after being duly sworn in
accordance with law, hereby depose and state that:
1. I am/We are the holder of Passbook (Peso/Dollar) Regular Savings/ESP/HYSA/Pension Account No.
with an outstanding balance of ₱/$ as of .

I am/We are the holder of ATM Savings Account/Current Account with ATM Access/
Peso EASY Check with ATM Access under Account No. /ATM Card No, with an
outstanding balance of
₱ as of .

I am/We are the holder of Peso/Dollar/HYUSDTD/CTD No. for ₱/$ dated

.

I am/We are the holder of Manager’s Check/FX Demand Draft/Gift Check for ₱/$
dated
which was drawn in Land Bank of the Philippines – (Name of Branch) in
favor of (Payee) .
 2. Sometime on or about (Date) , the above-mentioned Passbook/ATM Card/CTD/Manager’s
Check/FX Demand Draft/Gift Check was lost in my possession under the following
circumstances:
(state circumstances of loss)

3. Diligent efforts to search for the above-mentioned document were made and exhausted but all of which resulted in vain;

4. In view thereof, Landbank of the Philippines is hereby requested to issue a replacement for the lost Passbook/ATM Card/CTD/Manager’s Check/FX
Demand Draft/Gift Check and I/We bind myself/ourselves to surrender the lost Passbook/ATMCard/CTD/Manager’s Check/FX Demand Draft/Gift
Check in the event the same is found and/or located.

5. In consideration of the foregoing, I/We hereby bind myself/ourselves to indemnity the Landbank of the Philippines for any loss or damage it may incur
from any and all claims as well as costs and expenses in connection with the issuance of the new Passbook/ATM Card/CTD/Manager’s Checks/FX
Demand Draft/Gift Check covering the balance of ₱/$ , of the above-mentioned lost Passbook/ATM Card/CTD/Manager’s Check/FX Demand
Draft/Gift Check.

6. I/We hereby attest to the truth of the foregoing and I/We am/are willing to testify before any court of justice to substantiate the truth of each and all of
the aforesaid facts.

IN WITNESS WHEREOF, the undersigned signed these presents in , Philippines, on

this day of ,20 .

Name and Signature/s of Affiant/s Name and Signature/s of Affiant/s

SUBSCRIBED AND SWORN to before me in , Philippines, on this day of

, 20 , Affiant/s exhibiting to me his/her/their government issued ID , ID No.
, Issued on in , Philippines.

NOTARY PUBLIC

Doc. No. Page No.

Book No. Series of 20
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, REYNANTE PALMA RENDONRA, of legal age, Filipino,smarried, resident of Sto.Nino, Polanco,

Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am the Heir of late Spouses Apolinaria Rendora and Ruperto Rendora, registered owners of a parcel of
land, more particularly described as follows:

A parcel of land known as Lot 5052, Pls-66(Philcusa-FoA), covered by Original Certificate of Title No.127-P-
15612 situated at Tiniguiban,Leon B. Postigo(then part of Sindangan), Zamboanga del Norte, containing an area
of 146,999 square meters issued by the Register of Deeds for Zamboanga del Norte.

That I tried to look for the title from our ancestral house after I and my cousins decided to subdivide the land
and I even asked my cousins about it but nothing came into fruition;

That despite effort to recover the same but it was naught.

That I considered it as totally lost.

That I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for the purpose
of attesting to the loss of the said owner’s copy of Original Certificate of Title No.127-P-15612.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ____th day of _____________ 2024, at
Dipolog City.
REYNANTE PALMA RENDORA

(Affiant)

Drivers License#N03-05-016886

With photo

SUBSCRIBED AND SWORN to before me this ___th day of _________ 2024, at Dipolog City.

DOC.NO. ______

PAGE NO.___

BOOK NO.___

SERIES OF 2024

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, YVONNE LEGORIO GAHISAN, of legal age, Filipino, single, a resident of Linabo, Dapitan,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I was holder and possessor of a driver’s license issued by Land Transportation Office(LTO),.

That on 14 September 2024 at Dipolog City Airport, I discovered that the said driver’s license ID was
lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said driver’s license issued by LTO.

IN WITNESS WHEREOF, I have hereunto affixed my signature this 18th day of September 2024, at
Dipolog City.
 YVONNE LEGORIO GAHISAN
(Affiant)
Phil.ID#5045-3157-6430-1658
With photo

SUBSCRIBED AND SWORN to before me this 18th day of September 2024, at Dipolog City showing
his/her document of identity as indicated above.

DOC.NO.

PAGE NO.

BOOK NO.

SERIES OF 2024

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ANALIZA B. CEBALLOS, of legal age, Filipino, single/married, a resident of Purok Everlasting, Olingan,
Dipolog City, Zamboanga del Norte after having been duly sworn in accordance with law, hereby
depose and state:

That I am a holder and possessor of an Automated Teller Machine(ATM) cash card with number 6031
3100 0510 0051 492 issued by Landbank of the Philippines- Dipolog City Branch .

That recently, while I was trying to look for my said ATM Card, I found out that my said card was lost,
and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;
As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said Land Bank ATM card.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2024, at
Dipolog City.

ANALIZA B. CEBALLOS
(Affiant)
Valid ID#__________
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2024

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS
I, ERNIE O. MOSQUERA,JR, of legal age, Filipino, married, a resident of Purok Tunggo, Minaog, Dipolog
City, Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and
state:

That I am a holder and possessor of Sales Invoice No.50964 for Sony TV with SN 8862654 dated
8/21/2024 issued by Imperial Appliance Plaza-Dipolog City Branch.

That recently, while I was trying to look for my said receipt, I found out that my said receipt was lost,
and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said receipt.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2024, at
Dipolog City.

ERNIE O. MOSQUERA,JR
(Affiant)
Drivers License#J01-04-002627
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2024
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ROGELIO A. DAMPAYLA, of legal age, Filipino, married, a resident of Dapitan City, Zamboanga del
Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of Official Receipt with No.6170081 C dated April 8, 2019 issued by
Supreme Court for bailbond of Bernardo D. Acopiado for Criminal Case No.23032 at Regional Trial
Court Branch 7, Dipolog City.

That recently, while I was trying to look for my said receipt, I found out that my said receipt was lost,
and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said receipt.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2024, at
Dipolog City.

ROGELIO A. DAMPAYLA
(Affiant)
Valid ID#_______________
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2024
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, BENNY RAY E. ORACION, of legal age, Filipino, single, a resident of Segabe, Pi ñan, Zamboanga del
Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am holder and possessor of Armed Forces of the Philippine(AFP) Identification card as member
of AFP duly issued by AFP and Driver’s License issued by Land Transportation Office(LTO);.

That recently, my said AFP ID and Drivers License were lost;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said AFP ID and Driver’s License.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2024, at
Dipolog City.

BENNY RAY E. ORACION

(Affiant)
Pag-ibig MID#1212-8464-8681
WITH PHOTO

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at Dipolog City.

Doc. No.

Page No.

Book No.

Series of 2024
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, DECEMBER GAY GORION GANAGANAG, of legal age, Filipino, married, a resident of Silawe, Polanco,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of an Automated Teller Machine(ATM) card issued by Eastwest
Bank- Dipolog City Branch .

That recently, while I was trying to look for my said ATM Card, I found out that my said card was lost,
and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said Eastwest Bank ATM card.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2024, at
Dipolog City.

DECEMBER GAY GORION GANAGANAG

(Affiant)
PRC ID#1308865
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2024
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, RANDY RASONABE VALLECER, of legal age, Filipino, married, a resident of Miputak, Dipolog
City, Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and
state:

That I was holder and possessor of AFPMBAI Policy with Policy Number 2012060907;

That recently I decided to look for my said policy;

That however I found it was lost;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said policy contract.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2024, at
Dipolog City.

RANDY RASONABE VALLECER

(Affiant)
PNP ID#23A1900220
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at Dipolog City.

Doc. No.

Page No.

Book No.

Series of 2024
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ERNESTO J. ESCABARTE, of legal age, Filipino, married, a resident of Lot 15, Lot 14, Victoria Country
Homes Subd., Obay, Zamboanga del Norte after having been duly sworn in accordance with law,
hereby depose and state:

That I am a holder and possessor of a firearm, described as follows:

Make:Colt Kind:Pistl FA Lic.No.:896843I1679724

Caliber:45 Serial No.579155 Control No.:I-E0064596

That sometime December 2018, while I was in the Philippines having a vacation so I intended to
process the renewal of my said firearm. However, upon checking the said firearm where I kept it, I
could not locate it. The reason could be was that I was having a renovation of my house and I do not
know if one of the workers stole it. Thus, I considered it as lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said firearm.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019, at
Dipolog City.

ERNESTO J. ESCABARTE
(Affiant)
Firearm License Card Control No.I-E0064596

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2019
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ROSMINDA B. DIGAL, of legal age, Filipino, widow, a resident of Obay, Polanco, Zamboanga del
Norte after having been duly sworn in accordance with law, hereby depose and state:

That I was a holder and possessor of a BIR Certificate of Registration for PARK N’ BUY BAKERY, located
at Obay, Polanco, Zamboanga del Norte.

That recently, I discovered that the BIR Certificate of Registration was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said BIR Certificate of Registration and thereafter
requesting replacement thereon.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2024, at
Dipolog City.

ROSMINDA BRILLANTES DIGAL

(Affiant)
OSCA ID#21-04945-Polanco,ZN
With photo
SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at Dipolog City showing
his/her document of identity indicated above.
Doc. No.__
Page No.__
Book No.__
Series of 2024

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, RICHIE S. LIMOSNERO, of legal age, Filipino, single/married, a resident of Purok Bonifacio,

Punta, Dipolog City, Zamboanga del Norte after having been duly sworn in accordance with law,
hereby depose and state:

That I was holder and possessor of a driver’s license issued by Land Transportation Office(LTO),
Professional Regulation Commission(PRC) License issued by PRC, UMID ID, Philhealth ID, Pag-ibig
ID, Landbank of the Philippines ATM Card, BPI ATM Card, Ayuda Medical Card, add Big Heart
Card.
That recently, I discovered that the said ID’s were lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said valid IDs.

IN WITNESS WHEREOF, I have hereunto affixed my signature this 7th day of August 2024, at
Dipolog City.

RICHIE S. LIMOSNERO
(Affiant)
Valid ID#_________________
With photo

SUBSCRIBED AND SWORN to before me this 7th day of August 2024, at Dipolog City showing
his/her document of identity as indicated above.

DOC.NO.

PAGE NO.

BOOK NO.

SERIES OF 2024

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF TWO DISINTERESTED PERSONS

We: MAGDALENA P. PAGENTE and JANNET B. MONDIJAR, both of legal age, both
Filipinos, and with office address of Lingasad Elementary School, Lingasad,
Polanco, Zamboanga del Norte, after having been duly sworn in accordance with
law, hereby depose and state:
That we are Teachers of Lingasad Elementary School;

That we hereby attest that we were present and witnessed the fire incident at our
school;

That the fire incident happened on December 18, 2023 at around 10:06 in the
morning, the said incident razed three-classroom Bagong Lipunan Buildings of
said school;

That the following properties were inside the rooms during the said fire incident, to wit:

Ite DESCRIPTION QUANTI UNIT TOTAL REMARKS

m TY PRICE PRICE
No. (Php) (Php)

1 Television Set 3 sets 10,000. 30,000.0 Installed at

00 0 the rooms

2 Electric Fan 3 units 5,000.0 15,000.0 Installed at

0 0 the rooms

3 Ceiling Fan 6 units 4,500.0 13,500.0 Installed at

0 0 the rooms

4 Wall Fan 2 units 4,000.0 8,000.00 Installed at

0 the rooms

5 Pupil’s Table 12 3,500.0 42,000.0 Used by

pieces 0 0 pupils

6 Teacher’s Table 3 3,000.0 9,000.00 Used by

0 teachers
pieces

7 Aparador 3 units 5,000.0 15,000.0 Used by

0 0 teachers/pupi
ls

8 Plastic Chairs 60 500.00 30,000.0 Used by

pieces 0 teachers/pupi
ls

9 Chalkboard 9 2,000.0 18,000.0 Used by

pieces 0 0 teachers/pupi
ls

10 Refrigerator(Small) 1 unit 6,000.0 6,000.00 Used by

0 teachers/pupi
ls

11 Water Dispenser 1 unit 6,000.0 6,000.00 Used by

0 teachers/pupi
ls

12 Printer(3 in 1) 2 units 12,500. 25,000.0 Used by

 00 0 teachers

13 Rice Cooker 1 unit 800.00 800.00 Used by

teachers

14 Blender 1 unit 2,000.0 2,000.00 Used by

0 teachers/pupi
ls

15 Gas Burner 1 unit 4,500.0 4,500.00 Used by

0 teachers/pupi
ls

16 Frying Pan 1 piece 950.00 950.00 Used by

teachers/pupi
ls

17 Kettle(Big) 1 piece 850.00 850.00 Used by

teachers/pupi
ls

18 Cooking Pot 1 piece 750.00 750.00 Used by

teachers/pupi
ls

19 Drinking Glass 3 dozen 600.00 1,800.00 Used by

teachers/pupi
ls

20 Porcelain Plate 3 dozen 750.00 2,250.00 Used by

teachers/pupi
ls

21 Spoon & Fork 3 dozen 250.00 750.00 Used by

teachers/pupi
ls

22 Kitchen Knife 5 300.00 1,500.00 Used by

pieces teachers

23 Sports Equipment 5,000.00 Used by

teachers/pupi
ls

24 Educational Toys 1 set 5,500.0 5,500.00 Used by

0 teachers/pupi
ls

25 Cabinet 5 units 4,500.0 22,500.0 Used by

0 0 teachers/pupi
ls

26 A4 bondpapers 5 boxes 1,000.0 5,000.00 Used by

0 teachers/pupi
 ls

TOTAL 271,650.
00

That we hereby attest the existence of said assets/properties/inventories prior to

the fire incident as we had always used or seen these
assets/properties/inventories prior to its loss;

That as such, we are executing this Affidavit to attest to the truth of the foregoing
statements.

IN WITNESS WHEREOF, we have hereunto affixed our signatures this ___ day of
August 2024, at Dipolog City.

JANNET B. MONDIJAR MAGDALINA P. PAGENTE

(Affiant) (Affiant)

SUBSCRIBED AND SWORN to before me this ___ day of August 2024, at Dipolog City showing their documents of
identification:
Name Valid ID & Number Issuing Office
Jannet B. Mondijar 3198-2041-3281-0723 PSA
Magdalina P. Pagente 7483-7841-0917-5813 PSA

DOC.NO.

PAGE NO.

BOOK NO.

SERIES OF 2024

e Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, FREDERICK J. TABANCURA, of legal age, Filipino,single, resident of Biasong, Dipolog City, Zamboanga
del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am the Heir of late Spouses Siegfriedo C. Tabancura and Cecilia Jumalon-Tabancura, registered co-
owner of a parcel of land, more particularly described as follows:

A parcel of land known as Lot 14, Pcs-09-000460, covered by Transfer Certificate of Title No.T-3789 situated
at Gulayon, Dipolog City, Zamboanga del Norte, containing an area of 7,013 square meters issued by the
Register of Deeds for Dipolog City.
That I tried to look for the title from our ancestral house after I and my siblings decided to subdivide the land
and I even asked my siblings about it but nothing came into fruition;

That despite effort to recover the same but it was naught.

That I considered it as totally lost.

That I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for the purpose
of attesting to the loss of the said owner’s copy of Transfer Certificate of Title No.T-3789.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ____th day of _____________ 2024, at
Dipolog City.

FREDERICK J. TABANCURA

LEONILA J.ROSALES

(Affiant) (OSCA ID#18585)

Drivers license#J01-18-006040

With photo

SUBSCRIBED AND SWORN to before me this ___th day of _________ 2024, at Dipolog City.

DOC.NO. ______

PAGE NO.___

BOOK NO.___

SERIES OF 2024

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF HEIRSHIP WITH CONFORMITY

We: FITZINDEL TABANCURA, FREDERICK J. TABANCURA and ADAM MALIK

TABANCURA, all of legal age, all Filipinos, with address of Biasong, Dipolog City, Zamboanga del
Norte after having been duly sworn in accordance with law, hereby depose and state:

That we are the only children and heirs of late Spouses Siegfriedo C. Tabancura and Cecilia Jumalon,
who died and left parcel of land more particularly described as follows:

A parcel of land known as Lot 14, Pcs-09-000460, covered by Transfer Certificate of Title No.T-3789 situated
at Gulayon, Dipolog City, Zamboanga del Norte, containing an area of 7,013 square meters issued by the
Register of Deeds for Dipolog City.

That we have yet to execute partition document over the said land however the owner’s copy was lost;
That it was Frederick J. Tabancura who executed the affidavit of lost;

That we hereby consent and confirm to the act of Frederick J. Tabancura in replacing the owner’s copy
of the title after it was lost.

That we hereby attest the truthfulness of foregoing statements.

IN WITNESS WHEREOF, we have hereunto affixed our signatures this ___ day of __________ 2024,
at Dipolog City.

FREDERICK J. TABANCURA FITZINDEL TABANCURA ADAM MALIK TABANCURA

(Affiants)

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at Dipolog City.

Doc. No.
Page No.
Book No.
Series of 2024

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, FREDERICK J. TABANCURA, of legal age, Filipino,single, resident of Biasong, Dipolog City, Zamboanga
del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am the Heir of late Spouses Siegfriedo C. Tabancura and Cecilia Jumalon-Tabancura, registered co-
owner of a parcel of land, more particularly described as follows:

A parcel of land known as Lot 14, Pcs-09-000460, covered by Transfer Certificate of Title No.T-3789 situated
at Gulayon, Dipolog City, Zamboanga del Norte, containing an area of 7,013 square meters issued by the
Register of Deeds for Dipolog City.

That I tried to look for the title from our ancestral house after I and my siblings decided to subdivide the land
and I even asked my siblings about it but nothing came into fruition;

That despite effort to recover the same but it was naught.

That I considered it as totally lost.

That I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for the purpose
of attesting to the loss of the said owner’s copy of Transfer Certificate of Title No.T-3789.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ____th day of _____________ 2024, at
Dipolog City.

FREDERICK J. TABANCURA

(Affiant)

Drivers license#J01-18-006040

With photo

SUBSCRIBED AND SWORN to before me this ___th day of _________ 2024, at Dipolog City.

DOC.NO. ______

PAGE NO.___

BOOK NO.___

SERIES OF 2024

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ARSENIO P. LLIDO,JR, of legal age, Filipino, married, a resident of Dicayas,

Dipolog City, Zamboanga del Norte after having been duly sworn in accordance
with law, hereby depose and state:

That I was a holder and possessor of a sepia copy, and other copies of blueprint of
Approved Subdivision Plan PSD-9-091843 for parcel of land, situated at Dicayas,
DIpolog City, Zamboanga del Norte including the technical descriptions.

That recently while I was checking my file containing the said documents so that I
could process titling over said land, I found out that the documents were lost, and
could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it
as totally lost.
As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
statements and for the purpose of attesting to the loss of the said sepia copy, and
technical descriptions documents and request for replacement of the same.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2024, at Dipolog City.

ARSENIO P. LLIDO,JR
(Affiant)
Driver’s License#J04-82-012743

With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at Dipolog
City.

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS
I, ROSE LYN BARBA SAGARIO, of legal age, Filipino, a resident of VCH,
Obay, Polanco, Zamboanga del Norte, after having been duly sworn in
accordance with law, hereby depose and state:

That I was a holder and possessor of an AFPSLAI Red Passbook issued by

AFPSLAI;

That recently, while I was trying to look for the said AFPSLAI Passbook from
where I kept it, I found out that the AFPSLAI Passbook was lost, and could
not be found;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost;

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

foregoing statements and for the purpose of attesting to the loss of the said
AFPSLAI Red Passbook.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2024, at Dipolog City.

ROSE LYN BARBA SAGARIO

(Affiant)
PNP ID#22B2200609
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at

Dipolog City showing his/her document of identity as indicated above.

Doc No. _____

Page No. _____
Book No. ____
Series of 2024
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF CHANGE OF NAME

I:JOE VENCENT DAYMIEL PLAZUELA, of legal age, Filipino, single, a resident of Sicayab, Dipolog
City, Zamboanga del Norte after having been duly sworn in accordance with law, hereby
depose and state, that:

1. I am a passer of Civil Service Commission Eligibility as Career Service

Examination(Professional) passer;

2. I have been issued a certification by the Civil Service Commission with the name JOE
VINCENT DAYMIEL PLAZUELA;

3. There is a mistake in the entry of my first name JOE VINCENT before the Civil Service
Commission records as my true and correct first name is JOE VENCENT;

4. The JOE VINCENT D. PLAZUELA in the records of the Civil Service Commission pertains
to my person JOE VENCENT D. PLAZUELA;

5. JOE VINCENT D. PLAZUELA and JOE VENCENT D. PLAZUELA refer to one and the same
person;

6. There are no other changes in my personal circumstances but only the correction
of my first name from JOE VINCENT into JOE VENCENT;

7. This affidavit is executed to show and prove the above facts and in order to request
the government offices including but not limited to Civil Service Commission, other
offices to effect in their records my correct name from JOE VINCENT D. PLAZUELA to
JOE VENCENT D. PLAZUELA and update my records in the said offices;

8. This affidavit is also executed for all other purposes as may be required by law.

In witness whereof, I affix my signature this 29th day of July 2024 at Dipolog City.

JOE VENCENT D. PLAZUELA

Affiant

SUBSCRIBED AND SWORN before me this 29th day of July 2024 at Dipolog City, affiant
presented to me his valid identification card issued by government entity Drivers License No.
J01-22-301403 with his/her signature and picture therein.
Doc. No.

Page No

Book No

Series of 2024

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS
I:VINCENT TROY G. MONTE, of legal age, Filipino, married, a resident of
Dicayas, Dipolog City, Zamboanga del Norte after having been duly sworn
in accordance with law, hereby depose and state:

That I was a holder and possessor of Certificate of Registration of my vehicle

with Plate No.4273 , Chassis Number AX125A-B87240, Kawasaki Fury 125
issued by the Land Transportation Office(LTO) with Official Receipt(OR);

That during the flood in Dipolog City, my said certificate of registration with
OR was lost;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
certificate of registration with OR.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2024, at Dipolog City.

VINCENT TROY G. MONTE

(Affiant)

Philhealth Accreditation No.1100-1121830-2

With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at

Dipolog City showing her document of identification as indicated above.

Doc. No.

Page No.

Book No.

Series of 2024

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS
I, CLAIRE PAGE ELUMBA, of legal age, Filipino, a resident of Cawa-cawa, Dapitan City, Zamboanga del
Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a graduate at Saint Vincent’s College, Inc.-Dipolog City in year 2008;

That I was holder and possessor of a Diploma as a graduate of said school;

That recently I discovered that the original copy of my Diploma was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said document.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2024, at
Dipolog City.

CLAIRE PAGE-ELUMBA
(Affiant)
Driver’s License#J01-16-003059 valid until 2033/01/05
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at Dipolog City.

Doc. No.

Page No.

Book No.

Series of 2024
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I:NERIO E. GUMANSAG, of legal age, Filipino, single/married, a resident of

Upper Turno, Dipolog City, Zamboanga del Norte after having been duly
sworn in accordance with law, hereby depose and state:

That I was a holder and possessor of Official Receipt(OR) of renewal of

registration of vehicle with Plate No.KAB4214, Engine Number 1KD2782134,
Chassis Number JTFJT02P9H0008896 issued by the Land Transportation
Office(LTO) with Official Receipt(OR) registered in the name of my employer
Zamboanga del Norte Teachers and Employees Multi-purpose Cooperative;

That recently, I discovered that the said OR was lost;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
OR.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2024, at Dipolog City.

NERIO E. GUMANSAG

(Affiant)

Drivers License#J01-16-002409
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at

Dipolog City showing her document of identification as indicated above.

Doc. No.

Page No.

Book No.

Series of 2024
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF CONFORMITY

I: RUEL D. TABADA, of legal age, Filipino, with office address of Dipolog City Water District,
Minaog, Dipolog City, Zamboanga del Norte after having been duly sworn in accordance with law,
hereby depose and state:

That I am the General Manager of Dipolog City Water District, which is the precursor of NATIONAL
WATERWORKS AND SEWERAGE SYSTEM(NAWASA);

That NAWASA was the owner of portion of 89.155 square meters of Lot No.495 located at Estaka, Dipolog
City and covered by Transfer Certificate of Title No.(T-5877)1497 pursuant to title’s ENTRY NO. 4593;

That the other portions were still owned by the registered owner’s heirs/children which is Heirs of
Marcelina Royos;

That the heirs of Marcelina Royos intend to replace copy of the title over the said parcel of land and our
office has no objection thereto as we do not have copy of the original title;

That I hereby consent and confirm to the act of Nerissa S. Micubo, one of the heirs of Marcelina
Royos, in replacing the owner’s copy of the title after it was lost again.

That I hereby attest the truthfulness of foregoing statements.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2024, at
Dipolog City.

RUEL D. TABADA
Affiant

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at Dipolog City.

Doc. No.
Page No.
Book No.
Series of 2024
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ROSEMARY T. BASTASA, of legal age, Filipino, single, a resident of Egot, Dipolog City, Zamboanga del
Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am holder and possessor of my receipt for my Driver’s License issued by LTO.

That recently, my said receipt was lost;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said receipt.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2024, at
Dipolog City.

ROSEMARY T. BASTASA
(Affiant)
DL#J01-99-030166

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at Dipolog City.

Doc. No.

Page No.

Book No.

Series of 2024
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

CERTIFICATE OF AUTHENTICITY

I, JAYMARIE LOQUEZ BACA GARCIA, of legal age, Filipino, married, a resident of Purok 3 , New
Lebangon, Polanco, Zamboanga del Norte after having been duly sworn in accordance with law,
hereby depose and state:

That I am an artist, painter and creator of the following artworks titled,to wit:

1. AESTHETIC HORIZONS

2. GOLDEN TWILIGHT

3. MOONLIT SERENITY

4. COSTUM BIBLE VERSE

5. PSALM 127:2

6. THE LORD WILL RESCUE YOU

7. BIBLE VERSE ROMANS 8:13

8. LORD IS MY STRENGTH

9. CHERISH MOMENTS

That these artworks are original, authentic and genuinely created by the undersigned;

That I hereby declare that there are no other copies of these artworks;

That I am executing this certification to attest the truthfulness of foregoing statements.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2024, at
Dipolog City.

JAYMARIE LOQUEZ BACA GARCIA

(Affiant)
Philippine Driver’s License#J01-24-002191
With photo
SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at Dipolog City.

Doc. No.

Page No.

Book No.

Series of 2024

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF EXPLANATION

I, ANN L. FLORES, of legal age, Filipino, married, a resident of Gulayon,Dipolog City, Zamboanga del
Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a beneficiary/recipient/owner of housing unit at Obay Heights located at Obay, Polanco,

Zamboanga del Norte;

That I and my spouse named Jaylord Salavacion Sabida have already separated for long time already;

That during the acquisition over the said house, it was only me who acquired the above-said house
and my husband was not part thereof;

That I am executing this affidavit to justify the absence of marital consent in the conveyance of the
said house.

As such, I am executing this Affidavit to attest to the truth of the foregoing statements and for other
legal purposes.
IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2024, at
Dipolog City.

ANN L. FLORES
(Affiant)
Valid ID#__________
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at Dipolog City.

Doc. No.

Page No.

Book No.

Series of 2024

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, VIRGINIA B. LACAYA, of legal age, Filipino, married, a resident of Dipolog City, Zamboanga del Norte
after having been duly sworn in accordance with law, hereby depose and state:

That I was holder and possessor of original copy of Resolution issued by Honorable Regional Trial
Court Branch 6-Dipolog City under Misc. Sp. No. 10891.

That recently, I discovered the original copy was lost;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.
As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said original copy of Resolution.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2024, at
Dipolog City.

VIRGINIA B. LACAYA
(Affiant)
Valid ID#__________
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at Dipolog City.

Doc. No.

Page No.

Book No.

Series of 2024

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, DARYN MAY COMPANIA PARDILLADA-DALMACIO, of legal age, Filipino, married, a resident of

Poblacion North, Pinan, Zamboanga del Norte after having been duly sworn in accordance with law,
hereby depose and state:

That I am holder and possessor of Social Security System(SSS) Identification card.

That recently, my said SSS ID was lost;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said SSS ID.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2024, at
Dipolog City.

DARYN MAY COMPANIA PARDILLADA-DALMACIO

(Affiant)
Postal ID#PRNM83220350437P

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at Dipolog City.

Doc. No.

Page No.

Book No.

Series of 2024

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS
I, MARCELINA A. ONDIN, of legal age, Filipino, widow, a resident of Purok 1, Lipakan, Roxas,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am surviving spouse of Sgt. Nicolas A. Ongdin;

That he had been issued a retiree’s identification card as member of the Armed Forces of the
Philippines;

That I was holder and possessor of said AFP ID.

That on December 2, 2023, I discovered that the said ID was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said ID.

IN WITNESS WHEREOF, I have hereunto affixed my signature this 17th day of July 2024, at Dipolog
City.

MARCELINA A. ONDIN
(Affiant)
Phil ID#5216-2054-9725-9657
With photo

SUBSCRIBED AND SWORN to before me this 17th day of July 2024, at Dipolog City showing
his/her document of identity as indicated above.

DOC.NO.

PAGE NO.

BOOK NO.

SERIES OF 2024
6. There are no other changes in my personal circumstances but only the deletion of my
surname and like my date of birth remains the same;

7. This affidavit is executed to show and prove the above facts and in order to request
the government offices including but not limited to Civil Service Commission, Government
Service Insurance System, Social Security System, Philippine Health Insurance Corporation, and
other offices to effect in their records my court corrected name from KARL JOSHUA ENOY
JUMOC to KARL JOSHUA ENOY and update my records in the said offices;

8. This affidavit is also executed for all other purposes as may be required by law.

In witness whereof, I affix my signature this 3rd day of July 2024 at Dipolog City.

KARL JOSHUA ENOY

Affiant

SUBSCRIBED AND SWORN before me this 3 rd day of July 2024 at Dipolog City, affiant presented
to me his valid identification card issued by government entity PRC ID#1481741 with his/her
signature and picture therein.

Doc. No.

Page No

Book No

Series of 2024
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, IRENE M. VILLEJO, of legal age, Filipino, married, a resident of Gulayon, Dipolog City,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I was holder and possessor of a Manager’s Check issued by Landbank of the Philippines-Dipolog
City Branch.

That the Manager’s Check had the following details:

Name of Payee: Bideli Phils. Meridionale Speciale Caffe Inc.

Amount: P210,000.00

Date: 1/15/24

Check No.011528

That recently, I discovered that the said check was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said check.

IN WITNESS WHEREOF, I have hereunto affixed my signature this 3rd day of July 2024, at Dipolog
City.
 IRENE M. VILLEJO
(Affiant)
Drivers License# J01-02-040205
With photo

SUBSCRIBED AND SWORN to before me this 3rd day of July 2024, at Dipolog City showing his/her
document of identity as indicated above.

DOC.NO.

PAGE NO.

BOOK NO.

SERIES OF 2024

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, JULIVER MIRAFUENTES PASCULADO, of legal age, Filipino, single/married, a resident of San

Pedro, Polanco, Zamboanga del Norte after having been duly sworn in accordance with law, hereby
depose and state:

That I was holder and possessor of a driver’s license issued by Land Transportation Office(LTO),.

That recently, I discovered that the said driver’s license ID was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said driver’s license issued by LTO.
IN WITNESS WHEREOF, I have hereunto affixed my signature this 27th day of June 2024, at
Dipolog City.

JULIVER M. PASCULADO
(Affiant)
VIN7210-0086B-G1390JMP10000
With photo

SUBSCRIBED AND SWORN to before me this 27th day of June 2024, at Dipolog City showing
his/her document of identity as indicated above.

DOC.NO.

PAGE NO.

BOOK NO.

SERIES OF 2024

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, EMMA M. SABADO, of legal age, Filipino, widow of Sofronio B. Sabado, resident of 218 Purok
Namnam, Tawagan Norte, Labangan, Zamboanga del Sur after having been duly sworn in accordance
with law, hereby depose and state:
That I was the possessor and holder, together with my late spouse, of the owner’s duplicate copies of
the certificates of title of the following parcels of land, to wit:

1.Katibayan ng Orihinal na Titulo Blg.3,382 issued by ROD of Pagadian City for a parcel of land
denominated as Lot 570-B, Csd-09-008538-D(equivalent ot Lot 19145,Pls-119)located at Manga,
Pagadian City containing an area of 20,001 square meters;
2.Transfer Certificate of Title No.T-44,547 issued by the Register of Deeds of Province of
Zamboanga del Sur for a parcel of land known as Lot 14-A, Psd-097312-018448 located at
Tawagan Norte, Labangan, Zamboanga del Sur containing an area of 19,682 square meters
registered in the name of Nora B. Sabado and Ben Asis;
3. Transfer Certificate of Title No.T-25,306 issued by the Register of Deeds of Province of
Zamboanga del Sur for a parcel of land known as Lot 9, Psd-09-000474 located at Tawagan Norte,
Labangan, Zamboanga del Sur containing an area of 2,432 square meters;
4. Transfer Certificate of Title No.T-44,550 issued by the Register of Deeds of Province of
Zamboanga del Sur for a parcel of land known as Lot 14-D, Psd-097312-018448 located at
Tawagan Norte, Labangan, Zamboanga del Sur containing an area of 18,959 square meters;
5. Transfer Certificate of Title No.T-44,556 issued by the Register of Deeds of Province of
Zamboanga del Sur for a parcel of land known as Lot 14-J, Psd-097312-018448 located at Tawagan
Norte, Labangan, Zamboanga del Sur containing an area of 19,694 square meters;
6. Transfer Certificate of Title No.T-25,308 issued by the Register of Deeds of Province of
Zamboanga del Sur for a parcel of land known as Lot 11, Psd-09-000474 located at Tawagan Norte,
Labangan, Zamboanga del Sur containing an area of 2,432 square meters;
That we kept the owner’s duplicate copies of the title of above-said parcels of land at our house in
Purok Namnama,Tawagan Norte, Labangan, Zamboanga del Sur;

That on 03 September 2020, our house was devoured by fire. That the owner’s duplicate copies of the
title of the above-mentioned parcels of land were destroyed by the fire.

That we exerted efforts to recover the said owner’s duplicate copies of the titles but it was futile;

That as result, I considered it as totally lost.

That I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for the
purpose of attesting to the loss of the said owner’s copies of Katibayan ng Orihinal na Titulo Blg.3,382;
Transfer Certificate of Title No.T-44,547; Transfer Certificate of Title No.T-25,306; Transfer
Certificate of Title No.T-44,550 ; Transfer Certificate of Title No.T-44,556 ; and, Transfer Certificate
of Title No.T-25,308 .

IN WITNESS WHEREOF, I have hereunto affixed my signature this ____th day of _____________
2024, at Dipolog City.

EMMA MITUDA SABADO

(Affiant)

OSCA CONTROL NO.4560-Labangan, Zamboanga del Sur

With photo

SUBSCRIBED AND SWORN to before me this ___th day of _________ 2024, at Dipolog City with
the abovenamed person exhibiting his/her proof of identification as indicated above.

DOC.NO. ______
PAGE NO.___

BOOK NO.___

SERIES OF 2024

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ERIC T. MUIT, of legal age, Filipino, single/married, a resident of

Bandera, Polanco, Zamboanga del Norte, after having been duly sworn in
accordance with law, hereby depose and state:

That I am holder of original copy of BIR eCAR

#eCR2016000621343;duplicate copy of eCAR#eCR201600233619;eCAR
#201300233621;eCAR#201600233620; and receipt of estate tax payment
for TCT No.T-61845 located at Bandera, Polanco, ZN;

That on the same, while I was trying to look for the said papers the file
folder where I kept it, I found out that the said papers were lost, and could
not be found;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost;

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

foregoing statements and for the purpose of attesting to the loss of the said
papers.
IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of
__________ 2024, at Dipolog City.

ERIC T. MUIT
(Affiant)
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at

Dipolog City.

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, JASPER SIA TAN, of legal age, Filipino, married, a resident of Magsaysay St cor Tomas Claudio St.,
Miputak, Dipolog City, Zamboanga del Norte after having been duly sworn in accordance with law,
hereby depose and state:

That I am a holder and possessor of an Automated Teller Machine(ATM) Pitaka card issued by First
Consolidated Bank(FCB)- Dipolog City Branch .

That recently, while I was trying to look for my said ATM Pitaka Card, I found out that my said card
was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;
As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said FCB ATM Pitaka card.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2024, at
Dipolog City.

JASPER SIA TAN

(Affiant)
Drivers License#J01-09-002319
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2024

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF STATUS OF SPOUSE

I, CHERRY ANN C. BAYRON, of legal age, Filipino, married to Mikkel

Gronquist Jacobsen, a resident of Head Tipan, Mutia,Zamboanga del Norte,
after having been duly sworn in accordance with law, hereby depose and
state:

That I am buyer of portion of Lot 741 located at Head Tipan, Mutia,

Zamboanga del Norte covered by OCT No.P-4942;

That the name of my spouse was indicated as Mikkel Gronquist Jacobsen;

That the citizenship of my spouse is not Filipino;

That my spouse is a Swedish Citizen;

That I attest that the citizenship of my spouse be indicated as “Swedish”;

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2024, at Dipolog City.

CHERRY ANN C. BAYRON

(Affiant)
Valid ID#_________
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at

Dipolog City.

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, REBECCA A. DAJONAN, of legal age, Filipino, single/married, a resident of

Zamboanga del Norte, after having been duly sworn in accordance with law,
hereby depose and state:

That I was representative of owner, holder of duplicate copy of BIR eCAR

#eCR202200201548;and BIR stamped deed of donation over Lot 2-H,Psd-
09-038604 located at Nabilid, Roxas, Zamboanga del Norte notarized by
Atty Earl Russell S. Paulican under Doc No. 3358, Page No. 43, Book No.07,
Series of 2022;

That on the same, while I was trying to look for the said papers the file
folder where I kept it, I found out that the said papers were lost, and could
not be found;
That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost;

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

foregoing statements and for the purpose of attesting to the loss of the said
papers.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2024, at Dipolog City.

REBECCA A. DAJONAN
(Affiant)
Valid ID#_________
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at

Dipolog City.

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

SWORN STATEMENT

I, HAIDEE G. ONG, of legal age, Filipino, married, a resident of Dipolog City,

Zamboanga del Norte after having been duly sworn in accordance with law,
hereby depose and state:

That I am the Corporate Secretary of Rockefeller Poultry Farm Inc., located

at Labrador, Polanco, Zamboanga del Norte;

That I hereby attest that none of the incorporators/officials of proponent

Rockefeller Poultry Farm Inc. is related to the approving authority or
Regional Director of Department of Science and Technology Regional Office
IX within the third civil degree of consanguinity or affinity;

That I hereby further attest that proponent or its officials has no bad debts;

As such, I am executing this sworn statement to attest to the truth of the

foregoing statements.
IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of
__________ 2024, at Dipolog City.

HAIDEE G. ONG
(Affiant)
Valid ID#______________
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at

Dipolog City showing his/her document of identity as indicated above.

Doc. No.___

Page No.___

Book No.___

Series of 2024

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ELMER T. MONDIJAR, of legal age, Filipino, married, a resident of

Sta.Filomena, Dipolog City, Zamboanga del Norte after having been duly
sworn in accordance with law, hereby depose and state:

That I am Head Teacher I of Sto.Niño Elementary School, Polanco I District;

That I was a holder and possessor of Landbank Checks with Numbers

2626286 to 2626300 under Account No. 0512-1148-65 under Sto. Niño
Elementary School;

That on June 4, 2024 while I was traversing from ZANECO Piñan to Victoria
Hills Subdivision, Polanco I found out that those blank checks were lost
already;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.
As such, I am executing this Affidavit of Loss to attest to the truth of the
foregoing statements and for the purpose of attesting to the loss of the said
Landbank Checks.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2024, at Dipolog City.

ELMER T. MONDIJAR
(Affiant)
DepEd ID#1270022
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at

Dipolog City showing his/her document of identity as indicated above.

Doc. No.___

Page No.___

Book No.___

Series of 2024

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT

I, GLORIA D. CUBALAN, of legal age, Filipino, married, a resident of Gulayon,

Dipolog City, Zamboanga del Norte after having been duly sworn in
accordance with law, hereby depose and state:

That I am the Manager of Piñan National High School Multi-purpose

Cooperative;
That I hereby attest that the following cooperators/members have already
separated/resigned from the cooperative as members, to wit:

1. Antonietta Albon 2. Rebecca Cambalon

3.Cirila Maglangit 4.Fritzie Maglangit

5.Rosely Molero 6.Susan Padayhag

7.Alan Patangan 8.Marietta Rael

9.Kristy Sumalpong

That the reasons of their separation are either death or voluntary

termination of their membership;

That I am executing this Affidavit to attest to the truth of the foregoing

statements.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2024, at Dipolog City.

GLORIA D. CUBALAN
(Affiant)
UMID ID#CRN-006-0126-9544-9
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at

Dipolog City showing his/her document of identity as indicated above.

Doc. No.___

Page No.___

Book No.___

Series of 2024
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, BELEN V. PALER, of legal age, Filipino, married, a resident of Bolicon,

Turno, Dipolog City, Zamboanga del Norte after having been duly sworn in
accordance with law, hereby depose and state:

That I was a holder and possessor of a Landbank ATM card with Account
No.0517-1236-50;

That recently, I discovered that my ATM card was lost;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
ATM card.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2024, at Dipolog City.

BELEN V. PALER
(Affiant)
Valid ID#___________________
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at

Dipolog City showing his/her document of identity as indicated above.

Doc. No.___
Page No.___

Book No.___

Series of 2024

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, HENRY Y. UY, of legal age, Filipino, married, a resident of Dipolog City,

Zamboanga del Norte after having been duly sworn in accordance with law,
hereby depose and state:

That I was a holder and possessor of a sepia copy, and other copies of blueprint of
Approved Subdivision Plan PSD-09-078134 for parcel of land covered by TCT No.T-
5238, situated at Barra, DIpolog City, Zamboanga del Norte including the
technical descriptions.

That recently while I was checking my file containing the said documents so that I
could process titling over said land, I found out that the documents were lost, and
could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it
as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
statements and for the purpose of attesting to the loss of the said sepia copy, and
technical descriptions documents and request for replacement of the same.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2024, at Dipolog City.

HENRY Y. UY
(Affiant)

Valid ID#__________________

With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at Dipolog
City.

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, DANILO SUMILANG, of legal age, Filipino, married, a resident of Gulayon,

Dipolog City, Zamboanga del Norte, after having been duly sworn in
accordance with law, hereby depose and state:

That I was representative of Terry Refugio, holder of original copy of BIR

eCAR #eCR2016000621343;duplicate copy of
eCAR#eCR201600233619;eCAR #201300233621;eCAR#201600233620;
and receipt of estate tax payment for TCT No.T-61845 located at Bandera,
Polanco, ZN;

That on the same, while I was trying to look for the said papers the file
folder where I kept it, I found out that the said papers were lost, and could
not be found;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost;
As such, I am executing this Affidavit of Loss to attest to the truth of the
foregoing statements and for the purpose of attesting to the loss of the said
papers.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2024, at Dipolog City.

DANILO SUMILANG
(Affiant)
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at

Dipolog City.

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, MARK ZEUS M. SAILE, of legal age, Filipino, single, a resident of Blk 43, Lot 22, VCH, Obay,
Polanco, Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose
and state:

That I was holder and possessor of a driver’s license issued by Land Transportation Office(LTO),.

That recently, I discovered that the said driver’s license ID was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;
As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said driver’s license issued by LTO.

IN WITNESS WHEREOF, I have hereunto affixed my signature this 31st day of May 2024, at Dipolog
City.

MARK ZEUS M. SAILE

(Affiant)
Valid ID#__________
With photo

SUBSCRIBED AND SWORN to before me this 31st day of May 2024, at Dipolog City showing
his/her document of identity as indicated above.

DOC.NO.

PAGE NO.

BOOK NO.

SERIES OF 2024

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LENGTH OF SERVICE

I, ARLENE Z. TEJANO, of legal age, Filipino, single/married, resident of Lingasad, Polanco, Zamboanga del
Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am an employee of LGU-Municipality of Polanco, Zamboanga del Norte;

That I am qualified for Career Service Eligibility-Preference Rating(CSE-PR) granted by Civil Service
Commission(CSC) under CSC Resolution No.230112 dated 07 December 2023;
That I have been employee of the LGU since June 2005 until present as Job-Order/Contractual/and/or Casual-
Plantilla position;

That during my employment, I have total length of service of 11 years and 5 months;

That I hereby attest the truthfulness of my foregoing statement;

IN WITNESS WHEREOF, I have hereunto affixed my signature this ____th day of _____________ 2024, at
Dipolog City.

ARLENE Z. TEJANO

(Affiant)

LGU-Polanco Employee ID#097210-171

With photo

SUBSCRIBED AND SWORN to before me this ___th day of _________ 2024, at Dipolog City.

DOC.NO. ______

PAGE NO.___

BOOK NO.___

SERIES OF 2024

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LENGTH OF SERVICE

I, NIMFLOR M. BAIT-IT, of legal age, Filipino, single/married, resident of Villahermosa, Polanco,

Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am an employee of LGU-Municipality of Polanco, Zamboanga del Norte;

That I am qualified for Career Service Eligibility-Preference Rating(CSE-PR) granted by Civil Service
Commission(CSC) under CSC Resolution No.230112 dated 07 December 2023;

That I have been employee of the LGU since December 2004 until present as Job-Order/Contractual/and/or
Casual-Plantilla position;

That during my employment, I have total length of service of 13 years and 4 months;

That I hereby attest the truthfulness of my foregoing statement;

IN WITNESS WHEREOF, I have hereunto affixed my signature this ____th day of _____________ 2024, at
Dipolog City.

NIMFLOR M. BAIT-IT

(Affiant)

LGU-Polanco Employee ID#097210-367

With photo

SUBSCRIBED AND SWORN to before me this ___th day of _________ 2024, at Dipolog City.

DOC.NO. ______

PAGE NO.___

BOOK NO.___

SERIES OF 2024

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS
I, EDWIN JARDIN SORRONDA, of legal age, Filipino, married to Marlyn Atad, resident of Magsaysay St.,
Central Barangay, Dipolog City, Zamboanga del Norte after having been duly sworn in accordance with law,
hereby depose and state:

That I am the Heir of late Spouses Diogracias Sorronda and Angelita Jardin Sorronda, registered co-owner of a
parcel of land, more particularly described as follows:

A parcel of land known as Lot No.1605-I-2, covered by Transfer Certificate of Title No.T-30633 situated at
Galas, Dipolog City, Zamboanga del Norte, containing an area of 1,722 square meters issued by the Register of
Deeds for Dipolog City.

That I tried to look for the title from our ancestral house after we partitioned the land and I even asked my
siblings but nothing came into fruition;

That despite effort to recover the same but it was naught.

That I considered it as totally lost.

That I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for the purpose
of attesting to the loss of the said owner’s copy of Transfer Certificate of Title No.T-30633.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ____th day of _____________ 2024, at
Dipolog City.

EDWIN JARDIN SORRONDA

(Affiant)

Philhealth ID#14-250071724-5

With photo

SUBSCRIBED AND SWORN to before me this ___th day of _________ 2024, at Dipolog City.

DOC.NO. ______

PAGE NO.___

BOOK NO.___

SERIES OF 2024
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, LYNETTE M. GOMEZ, of legal age, Filipino, a resident of Dipolog City, Zamboanga del Norte after
having been duly sworn in accordance with law, hereby depose and state:

That I was a holder and possessor of a BIR Certificate of Registration for Farmaxpress Pharmacy,
located at Sta.Cruz, Dapitan City.

That recently, I discovered that the BIR Certificate of Registration was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said BIR Certificate of Registration and thereafter
requesting replacement thereon.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2024, at
Dipolog City.

LYNETTE M. GOMEZ
(Affiant)
Valid ID#_________
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at Dipolog City showing
his/her document of identity indicated above.
Doc. No.__
Page No.__
Book No.__
Series of 2024
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, MARIA GALVICS S. LIM-EROY, of legal age, Filipino, a resident of Dipolog City, Zamboanga del Norte
after having been duly sworn in accordance with law, hereby depose and state:

That I was a holder and possessor of a BIR Certificate of Registration for Pepic’s Lodge, located at
Central, Dipolog City.

That recently, I discovered that the BIR Certificate of Registration was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said BIR Certificate of Registration and thereafter
requesting replacement thereon.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2024, at
Dipolog City.

MARIA GALVICS L. EROY

(Affiant)
Valid ID#_________
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at Dipolog City showing
his/her document of identity indicated above.
Doc. No.__
Page No.__
Book No.__
Series of 2024
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ESPERANZA V. MUIT, of legal age, Filipino, married, a resident of Turno,Dipolog City, Zamboanga
del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I was a holder and possessor of an Automated Teller Machine(ATM) card issued by Land Bank of
the Philippines (LBP) Dipolog City Branch with Account Number 0517-1282-36.

That recently, I discovered that the LBP ATM card was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said LBP ATM card and thereafter requesting replacement
thereon.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2023, at
Dipolog City.

ESPERANZA V. MUIT
(Affiant)
Phil. ID#3179-6307-2491-8536
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at Dipolog City showing
his/her document of identity indicated above.
Doc. No.__
Page No.__
Book No.__
Series of 2024
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, MERLINDA NAYAL MACAUILI, of legal age, Filipino, a resident of Isis, Polanco, Zamboanga del
Norte after having been duly sworn in accordance with law, hereby depose and state:

That I was holder and possessor of a driver’s license issued by Land Transportation Office(LTO),.

That recently, I discovered that the said driver’s license ID was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said driver’s license issued by LTO.

IN WITNESS WHEREOF, I have hereunto affixed my signature this 24th day of May 2024, at
Dipolog City.

MERLINDA NAYAL MACAUILI

(Affiant)
DL#G0116005308
With photo

SUBSCRIBED AND SWORN to before me this 24th day of May 2024, at Dipolog City showing
his/her document of identity as indicated above.

DOC.NO.

PAGE NO.

BOOK NO.

SERIES OF 2024

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x
 AFFIDAVIT OF LOSS

I, TEDDAVE S. EVARDO, Filipino, of legal age, married , and a resident of

Central, Dipolog City, Zamboanga del Norte after having been duly sworn in
accordance with law, hereby depose and state:

That I was a holder and possessor of receipt with number 61371NP003979

dated 10 February 2024 issued by Cebuana Lhuillier for pawned jewelry
described as Necklace w/ Cont.Pendant in the amount of P13,282.50;

That recently, I found out that my receipt was lost, I tried to locate the
receipts but it was really lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
receipt.

IN WITNESS WHEREOF, I have hereunto affixed my signature this 24 th day of

May 2024, at Dipolog City.

TEDDAVE S. EVARDO
(Affiant)
UMID ID#CRN-001-0068-6587-9
With phot

SUBSCRIBED AND SWORN to before me this 24th day of May 2024, at

Dipolog City.

Doc. No.5079
Page No.28
Book No.X
Series of 2024
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, LITO ALLA LECERA, of legal age, Filipino, married, a resident of Purok 3, Basagan, Katipunan,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I was holder and possessor of a driver’s license issued by Land Transportation Office(LTO),.

That on May 21, 2024, I discovered that the said driver’s license ID was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said driver’s license issued by LTO.

IN WITNESS WHEREOF, I have hereunto affixed my signature this 23rd day of May 2024, at
Dipolog City.

LITO ALLA LECERA

(Affiant)
DENR Employee ID#DENR-2013-11014665
With photo

SUBSCRIBED AND SWORN to before me this 23rd day of May 2024, at Dipolog City showing
his/her document of identity as indicated above.

DOC.NO.

PAGE NO.

BOOK NO.

SERIES OF 2024
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT

I, CHARLEMAGNE C. SEVILLA, of legal age, Filipino, married, with office address of Sevilla
Power Enginering & Services, Tomas Claudio St., Dipolog City, Zamboanga del Norte after having
been duly sworn in accordance with law, hereby depose and state:

That I am the proprietor of Sevilla Power Engineering & Services;

That the abovenamed company is engaged in construction business;

That the said business engaged construction workers from project to project basis only, if there is a
project then we hire laborers, skilled workers and construction related workers;

That I know the complainants in this case of SRABIX-05-00006-2024 namely:Joel P. Cantorias and
Ronal T. Natividad;

That all of the complainants were perennial absentees at the construction site of the company which is
the Top Rice Mill Building Construction at Dipolog City;

That from time to time, they incurred absences however the company just tolerated it because we need
laborers and employees at the construction site;

That there were times that these employees went absent for weeks but we just let it pass because we
needed their services;

That their absences became normal to us that when they returned to work we accepted them without
question;

That we were just surprised that they went to the Labor when it was them who went AWOL;

That I still consider them as employees because they were not dismissed or terminated by the company;

That I hereby attest that it is not true that they were dismissed as they were not terminated in any way;

That as regards to their 13th month pay, it is already added to their daily wage because the nature of our
project does not go beyond one(1) year or it usually has a timeframe of six(6) months or even less so
we already added the 13th month pay in their daily wage.

That I am executing this Affidavit to attest to the truth of the foregoing statements.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of May 2024, at Dipolog
City.

CHARLEMAGNE C. SEVILLA
(Affiant)
PRC ID#0004422
With photo
SUBSCRIBED AND SWORN to before me this ___ day of May 2024, at Dipolog City showing
his/her document of identity as indicated above.

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, MADELYN C. EMBRADO, of legal age, Filipino, married, a resident of

Estaka, Dipolog City, Zamboanga del Norte, after having been duly sworn in
accordance with law, hereby depose and state:

That I am a holder and possessor of a National Certificate known as NC II for

Natural Wellness Massage issued by TESDA;

That recently, I found out that the original document was lost, and could not
be found;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost;

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

foregoing statements and for the purpose of attesting to the loss of the said
document.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

May 2024, at Dipolog City.

MADELYN C. EMBRADO
(Affiant)
Philhealth ID#6149-8319-9763-5136
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of May 2024, at Dipolog
City.

Doc. No

Page No

Book No

Series of 2024
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT

We: ROBERTO P. BASTILLADA and ALEX L. PATRON,JR, both of legal age, both Filipinos, both
married, both residents of Olingan, and Sta. Filoeman, respectively, Dipolog City, Zamboanga del
Norte after having been duly sworn in accordance with law, hereby depose and state:

That I: Roberto P. Bastillada, am the Foreman of Sevilla Power Engineering & Services, owned by
Charlemagne C. Sevilla; That I: Alex L. Patron,Jr., am the Timekeeper of the same company;

That the abovenamed company is engaged in construction business;

That we are responsible in supervising the employees of the abovenamed company at the construction
site;

That we know the complainants in this case of SRABIX-05-00006-2024 namely:Joel P. Cantorias and
Ronald T. Natividad because they were under our supervision;

That they were engaged on a project basis, with the complainants were hired at Top Rice Mill
Construction Project, Dipolog City. That their employment depended on every project contracted by
Sevilla so their employment is not continuous;

That like most small time construction companies, we have experienced frequent absences from our
laborers, steelmen, and skilled workers due to their engagement with other construction project from
time to time;

That in this case, Joel P. Cantorias and Ronald T. Natividad were some of the employees who went
absent from time to time without notice and we even reprimanded them because we needed them to
meet the deadline of the project but they took it against us and they still left or abandon their post from
time to time at their own convenience;

That their absences became normal to us that when they returned to work we accepted them without
question;

That we were just surprised that they went to the Labor when it was them who went AWOL and we
still considered them as employees as we did not dismiss them or terminate them;

That it is not true that they were dismissed;

That we are executing this Affidavit to attest to the truth of the foregoing statements.

IN WITNESS WHEREOF, we have hereunto affixed our signatures this ___ day of May 2024, at
Dipolog City.
ROBERTO P. BASTILLADA ALEX L. PATRON.JR
(Affiant) (Affiant)
Drivers License#J01-23-006254 Drivers License#J01-10-002242
With photo With photo

SUBSCRIBED AND SWORN to before me this ___ day of May 2024, at Dipolog City showing
his/her document of identity as indicated above.

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT

We: ROBERTO P. BASTILLADA and ALEX L. PATRON,JR, both of legal age, both Filipinos, both
married, both residents of Olingan, and Sta. Filoeman, respectively, Dipolog City, Zamboanga del
Norte after having been duly sworn in accordance with law, hereby depose and state:

That I: Roberto P. Bastillada, am the Foreman of Sevilla Power Engineering & Services, owned by
Charlemagne C. Sevilla; That I: Alex L. Patron,Jr., am the Timekeeper of the same company;

That the abovenamed company is engaged in construction business;

That we are responsible in supervising the employees of the abovenamed company at the construction
site;

That we know the complainants in this case of SRABIX-04-00014-2024 namely:Roger J. Quintana,Jr

and Dindo E. Sorbito because they were under our supervision;

That they were engaged on a project basis, with the complainants were hired at Top Rice Mill
Construction Project, Dipolog City. That their employment depended on every project contracted by
Sevilla so their employment is not continuous;

That like most small time construction companies, we have experienced frequent absences from our
laborers, steelmen, and skilled workers due to their engagement with other construction project from
time to time;

That in this case, Roger J. Quintana and Dindo E. Sorbito were some of the employees who went
absent from time to time without notice and we even reprimanded them because we needed them to
meet the deadline of the project but they took it against us and they still left or abandon their post from
time to time at their own convenience;

That their absences became normal to us that when they returned to work we accepted them without
question;

That we were just surprised that they went to the Labor when it was them who went AWOL and we
still considered them as employees as we did not dismiss them or terminate them;

That it is not true that they were dismissed;

That we are executing this Affidavit to attest to the truth of the foregoing statements.

IN WITNESS WHEREOF, we have hereunto affixed our signatures this ___ day of May 2024, at
Dipolog City.
ROBERTO P. BASTILLADA ALEX L. PATRON.JR
(Affiant) (Affiant)
Drivers License#J01-23-006254 Drivers License#J01-10-002242
With photo With photo

SUBSCRIBED AND SWORN to before me this ___ day of May 2024, at Dipolog City showing
his/her document of identity as indicated above.

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT

I, CHARLEMAGNE C. SEVILLA, of legal age, Filipino, married, with office address of Sevilla
Power Enginering & Services, Tomas Claudio St., Dipolog City, Zamboanga del Norte after having
been duly sworn in accordance with law, hereby depose and state:

That I am the proprietor of Sevilla Power Engineering & Services;

That the abovenamed company is engaged in construction business;

That the said business engaged construction workers from project to project basis only, if there is a
project then we hire laborers, skilled workers and construction related workers;

That I know the complainants in this case of SRABIX-04-00014-2024 namely:Roger J. Quintana,Jr and
Dindo E. Sorbito;

That all of the complainants were perennial absentees at the construction site of the company which is
the Top Rice Mill Building Construction at Dipolog City;

That from time to time, they incurred absences however the company just tolerated it because we need
laborers and employees at the construction site;

That there were times that these employees went absent for weeks but we just let it pass because we
needed their services;

That their absences became normal to us that when they returned to work we accepted them without
question;

That we were just surprised that they went to the Labor when it was them who went AWOL;

That I still consider them as employees because they were not dismissed or terminated by the company;

That I hereby attest that it is not true that they were dismissed as they were not terminated in any way;

That as regards to their 13th month pay, it is already added to their daily wage because the nature of our
project does not go beyond one(1) year or it usually has a timeframe of six(6) months or even less so
we already added the 13th month pay in their daily wage.

That I am executing this Affidavit to attest to the truth of the foregoing statements.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of May 2024, at Dipolog
City.
 CHARLEMAGNE C. SEVILLA
(Affiant)
Valid ID#_______________
With photo

SUBSCRIBED AND SWORN to before me this ___ day of May 2024, at Dipolog City showing
his/her document of identity as indicated above.

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, CINDERELLA A. DY, of legal age, Filipino, single, a resident of 549 Noli Me Tangere St., Dapitan
City, Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and
state:

That I was holder and possessor of a driver’s license issued by Land Transportation Office(LTO),.

That on April 25, 2024, I discovered that the said driver’s license ID was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said driver’s license issued by LTO.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of April 2024, at
Dipolog City.

CINDERELLA A. DY
(Affiant)
J01-01-035404
With photo

SUBSCRIBED AND SWORN to before me this ___ day of April 2024, at Dipolog City showing
his/her document of identity as indicated above.

DOC.NO.

PAGE NO.

BOOK NO.

SERIES OF 2024
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, MARY GRACE M. PUSTA, of legal age, Filipino, married, a resident of Libertad, Sapang Dalaga,
Misamis Occidental after having been duly sworn in accordance with law, hereby depose and state:

That I was holder and possessor of a driver’s license issued by Land Transportation Office(LTO).

That on May 7, 2024, 2024, I discovered that the said driver’s license ID was lost, and could not be
found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said driver’s license issued by LTO.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of May 2024, at Dipolog
City.

MARY GRACE M. PUSTA

(Affiant)
PRC ID#0829858-Nurse
With photo

SUBSCRIBED AND SWORN to before me this ___ day of May 2024, at Dipolog City showing
his/her document of identity as indicated above.

DOC.NO.

PAGE NO.

BOOK NO.

SERIES OF 2024
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT

I, JHUN PHILIP A. ELOPRE, of legal age, Filipino, single, a resident of Sto.

Niǹo, Polanco, Zamboanga del Norte after having been duly sworn in
accordance with law, hereby depose and state:

That I was involved in a vehicular accident that transpired at about 5:48pm

along national highway,Conacon, Poblacion North, Polanco, Zamboanga del
Norte between a motor vehicle Honda Beat color white bearing temporary
plate number 0908-03374270 and another motor vehicle Honda Beat color
blue/black bearing temporary plate number 0901-053817;

That the Honda Beat color white bearing temporary plate number 0908-
03374270 was recorded in the police incident record form or blotter to be
driven by KENNETH JOHN QUIRANTE RENDORA.

That the truth of the matter is that I was the one who was driving the said
motor vehicle at the time of incident;

That the record was not made right during the taking of testimony because I
was drunk as well as the other parties of the accident however today as I
am already not drunk anymore I can clearly say that KENNETH JOHN
QUIRANTE RENDORA did not drive the vehicle but I am;

That KENNETH JOHN QUIRANTE RENDORA was just a pillion rider of

undersigned.

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

statements and to correct the police blotter of the Philippine National Police.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

May 2024, at Dipolog City.

JHUN PHILIP A. ELOPRE

(Affiant)
Drivers License#J01-20-010312
With photo

Attestation
I, RANDY D. PANCHO, am the other rider of motor vehicle that was involved
in the said accident. I hereby attest that JHUN PHILIP A. ELOPRE is other
rider of opposing vehicle while KENNETH JOH QUIRANTE RENDORA was just
the pillion rider of Jhun Philip A. Elopre.

RANDY D. PANCHO

SUBSCRIBED AND SWORN to before me this ___ day of May 2024, at Dipolog
City.

DOC.NO.

PAGE NO.

BOOK NO.

SERIES OF 2024

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, JAIME GONZALES ANG, of legal age, Filipino, a resident of Burgos St.,

Miputak, Dipolog City, Zamboanga del Norte after having been duly sworn
in accordance with law, hereby depose and state:

That I was holder and possessor of OSCA Identification(ID) card issued by

Office of Senior Citizen’s Affairs(OSCA).

That recently, I discovered that my said OSCA ID card was lost, and could
not be found;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost;
As such, I am executing this Affidavit of Loss to attest to the truth of the
foregoing statements and for the purpose of attesting to the loss of the said
OSCA ID card.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

May 2024, at Dipolog City.

JAIME GONZALES ANG

(Affiant)
Valid ID#__________________
With photo

SUBSCRIBED AND SWORN to before me this ___ day of May 2024, at Dipolog
City.

DOC.NO.

PAGE NO.

BOOK NO.

SERIES OF 2024

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, SEVELINA PROTACIO, Filipino, of legal age, married , and a resident of

Silano, Piǹan, Zamboanga del Norte after having been duly sworn in
accordance with law, hereby depose and state:
That I was a holder and possessor of receipt with number 132101448-2024-
0006 dated 16 January 2024 issued by MLhuillier for pawned jewelry
describd as 1 2 Tone PR Earrings Def 18K, 2.1 grams in the amount of
P6,000.00;

That recently, I found out that my receipt was lost, I tried to locate the
receipts but it was really lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
receipt.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2024, at Dipolog City.

SEVELINA PROTACIO
(Affiant)
Valid ID#____________
With phot

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at

Dipolog City.

Doc. No.__
Page No.__
Book No.__
Series of 2024

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x
 AFFIDAVIT OF LOSS

I, MARVIN C. EMPAO, Filipino, of legal age, single, and a resident of Igot,

Turno, Dipolog City, Zamboanga del Norte after having been duly sworn in
accordance with law, hereby depose and state:

That I was a holder and possessor of receipt issued by Palawan Pawnshop-

Dumaguete City Branch for pawned jewelry with
No____________________________________________;

That recently, I found out that my receipt was lost, I tried to locate the
receipts but it was really lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
receipt.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2024, at Dipolog City.

MARVIN C. EMPAO
(Affiant)
Valid ID#_______________
With phot

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at

Dipolog City showing his/her document of identity with its number indicated
above.

Doc. No.__
Page No.__
Book No.__
Series of 2024
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, FLORDELYN G. NEVALISA, Filipino, of legal age, married, and a resident of

Gulayon, Dipolog City, Zamboanga del Norte after having been duly sworn
in accordance with law, hereby depose and state:

That I was a holder and possessor of receipt issued by Cebuana Lhuillier-

Dipolog 4 Branch for pawned jewelry Pulcera Bangle in the amount of
P32,160.00 under Pawnticket No.50306NP012133, dated December 28,
2023;

That recently, my said receipt was lost;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
receipt.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2024, at Dipolog City.

FLORDELYN G. NEVALISA
(Affiant)
UMID ID#CRN-006-0110-6753-1
With phot

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at

Dipolog City.

Doc. No.__
Page No.__
Book No.__
Series of 2024
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT

I, JOHN MELGRE L. CATALBAS, of legal age, Filipino, married, a resident of

Rizal Ave., Dipolog City, Zamboanga del Norte, after having been duly sworn
in accordance with law, hereby depose and state:

That I am the proprietor of ARJOHN PHONE LAND & GENERAL MERCHANDISE

located at Enerio St., Oroquieta City, Misamis Occidental;

That as proprietor, I was a permit to use sales machine issued by the

Bureau of Internal Revenue;
That the details of the sales machine used by the undersigned is, to wit:

Type of Sale Machine Software Machine Permit

Machine Details(Brand/ Details Identification Number
Model/ Serial (Name/ Number
Number) Version)

Standalone Assistant POS Assistant 130326144 0813-100-

Software/Professi POS 183368-002
onal /S2ACYMLZ Software
vProfessional

That on December 26, 2022, my store suffered from the heavy floods in
Oroquieta City and one of the items that was lost is the above-mentioned
sales machine;

That the sales machine became completely unusable;

That the office of Bureau of Internal Revenue in Oroquieta City was already
informed about the lost of the sales machine;
That recently, we disposed the said sales machine and threw it away as it is
beyond salvage anymore;

That I could no longer surrender the said sales machine to the Bureau of
Internal Revenue because it was disposed already;

That I am executing this affidavit to support the non-surrender of sales

machine with abovementioned details to the Bureau of Internal Revenue;

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

statements and for other legal purposes.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

May 2024, at Dipolog City.

JOHN MELGRE L. CATALBAS

(Affiant)
TIN#936-105-479
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of May 2024, at Dipolog
City showing his document of identity as indicated above.

Doc. No

Page No

Book No

Series of 2024
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, MICA B. BASTASA, of legal age, Filipino, single, a resident of Olingan,

Dipolog City, Zamboanga del Norte, after having been duly sworn in
accordance with law, hereby depose and state:

That I was a holder of Certificate of Attendance issued by Saint Vincent’s

College, Inc. on the orientation prior to our deployment for internship;

That recently, I found out that the original document was lost, and could not
be found;
That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost;

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

foregoing statements and for the purpose of attesting to the loss of the said
document.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

May 2024, at Dipolog City.

MICA B. BASTASA
(Affiant)
SVC School ID#2021-05716
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of May 2024, at Dipolog
City.

Doc. No

Page No

Book No

Series of 2024

JOHN MELGRE L. CATALBAS, of legal age, both Filipino, married, resident of Rizal Ave.,
Dipolog City, Zamboanga del Norte

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS
I, ALESTRE MAE GUIA MANOGURA, of legal age, Filipino, single, a resident of
Obay, Polanco, Zamboanga del Norte, after having been duly sworn in
accordance with law, hereby depose and state:

That I was a holder of Certificate of Attendance issued by Saint Vincent’s

College, Inc. on the orientation prior to our deployment for internship;

That recently, I found out that the original document was lost, and could not
be found;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost;

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

foregoing statements and for the purpose of attesting to the loss of the said
document.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

May 2024, at Dipolog City.

ALESTRE MAE GUIA MANOGURA

(Affiant)
Drivers License#J01-20-011376
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of May 2024, at Dipolog
City.

Doc. No

Page No

Book No

Series of 2024
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ROSAN OBSIOMA BALLADARES, of legal age, Filipino, married, a resident of Tolon, Rizal, Zamboanga
del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am the daughter of JESUSA TORINO OBSIOMA, who is already dead;

That before she died, she informed me that she was a member of Paglaum Multi-purpose
Cooperative- Rizal, ZN Branch, with address of Mapang, Rizal, Zamboanga del Norte; That she has
passbook in the said cooperative;

That after she died I was looking for the passbook of the said cooperative, but it was lost, and could
not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said passbook.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2024, at
Dipolog City.

ROSAN OBSIOMA BALLADARES

(Affiant)
VIN#7212-0041A-B1878ROB20000
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2024
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ANGIELIE CAJOCON CERVANTES, of legal age, Filipino, a resident of

Poblacion North, Polanco, Zamboanga del Norte, after having been duly
sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of a Competency Assessment Result

Summary of National Certificate known as NC II Caregiving Certificate issued
by TESDA;

That recently, I found out that the original document was lost, and could not
be found;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost;

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

foregoing statements and for the purpose of attesting to the loss of the said
document.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

May 2024, at Dipolog City.

ANGIELIE CAJOCON CERVANTES

(Affiant)
UMID ID#CRN-021-1368-9535-3
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of May 2024, at Dipolog
City.

Doc. No

Page No

Book No

Series of 2024
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

SWORN STATEMENT EXPRESSING SUPPORT

I, PRINCESS MAE D. LADERA, of legal age, Filipino, single, with address of Dipolog City,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and
state:

That I am the Roland B. Ladera and Ma. Tessie D. Ladera.

That I execute this affidavit expressing support to my father regarding the complaint filed by
my mother;

That I attest that my father has always been supporting us financially eversince he and my
mother separated from each other;

That it was my father who supported me and my brother Kimberly to school that is why we are
already professionals now and we have been employed by the government;

That my brother has been working in Sirawai, Zamboanga del Norte which is more or less
six(6) hours of travel going to Dipolog City( the place of my father) but I can attest that my
brother will also express support to our father;

That my father did not ever abandon us, my father did not left us and did not ever fail to feed
us. Although the marital relations between my parents turned sour but I always love and support
both of my parents. It is just disheartening that my mother continues to harass my father
although they have been living out from each other’s lives for more than a decade now.

That I know my mother has her own life now as well as my father but it is not fair with my
father to be harassed continuously by my mother;

That I and brother are not anymore dependent with my father because we have been gainfully
employed yet he would sometimes extend to us assistance and even gave us properties so that
we would not ask anymore from him.

That I attest that all of the complaint of my mother are just baseless and there is no truth to it,
she just wants to drain off money from him.

That I plea that the complaint of my mother be dismissed for being lack of merit and it is just a
mere harassment against our father.

As such, I am executing this statement to attest to the truth of the foregoing statements.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of May 2024, at
Dipolog City.
 PRINCESS MAE D. LADERA
(Affiant)
PRC ID#0145129
Valid until 4-16-2026
With photo

SUBSCRIBED AND SWORN to before me this ___ day of May 2024, at Dipolog City
showing his/her document of identity as indicated above.

Doc. No.

Page No.

Book No.

Series of 2024
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

SWORN EXPLANATION/COMMENT

I, ROLAND B. LADERA, of legal age, Filipino, married, with office address of Roxas Fire
Station, Pres. MA Roxas, Zamboanga del Norte after having been duly sworn in accordance
with law, hereby depose and state:

That I am the Deputy Municipal Fire Marshall of Pres.MA Roxas, Zamboanga del Norte.

That I received the Memoradum issued by Atty. Jayson T. Molejon, FCINSP, Chief of RIAS,
BFP, Regional Office IX on May 1, 2024, requiring the undersigned to submit
explanation/comment under oath regarding the complaint of my spouse Ma. Tessie D. Ladera
within five(5) days from receipt, hence I am submitting my Sworn Explanation/Comment
within the reglementary period;

That the complaint of my spouse dated April 30, 2024 stated “My husband SFO4 Roland B.
Ladera, abandon us and left our family dwelling and though it is his obligation to feed our
family.[emphasis underlined]” She also attached her letter-communication dated June 8, 2011
addressed to PIAS of the BFP-Regional Office IX regarding her complaint on violation of RA
9262.

That I am categorically denying all of the above-stated allegations. I specifically deny that I
abandon my family and I left the family dwelling and I did not feed my family.

That the truth of the matter is that: I and my spouse separated from each other for quite
sometime already(more than a decade already). I did not leave our conjugal dwelling but it was
her who asked me to leave. Then later she left our conjugal dwelling after my two(2) children
caught her having another man at our conjugal dwelling.

She filed a VAWC case against me but those were dismissed by the Honorable Prosecutor
(please attached Annexes 1,2, & 3).

I supported them financially including the subsistence and studies of my two children Kimberly
and Princess Mae;

However, my child Princess Mae came to me and so I personally took custody of my said child
while also still continued supporting my child Kimberly who lives at our conjugal home without
her mother, who is living with another man in Roxas, Zamboanga del Norte.
With my support, both of my children finished studies now, both have degrees as professionals
and both are gainfully employed as government employees. Even now, I still continue
supporting my children despite they are already professionals.

My child Princess Mae can attest to this as I attached in this sworn explanation her statement of
support for me(marked as Annex 4) while my other child Kimberly can attest also but he is
living in another place particularly Sirawai, Zamboanga del Norte;

Moreover, I and my wife had a settlement before that is why the Prosecutor dismissed her
complaint against me. We executed settlement on the allotment of support towards my family
sometime in year 2011.Attached is the minutes of meeting at RIAS 9 as Annex 5 wherein we
agree to settle and we needed finalization on the amount of support.

I categorically state that my wife raised this complaint in order to get money from me as she did
before in filing uncorroborated and pure fabrication complaints against me. She shops around in
order to get favorable judgment against me and to get money from me. But all of those were
dismissed by the prosecutor.

I plea that this letter be discard for lack of merit and just a wanton grievance by a wife whom I
separated with for more than a decade already.

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

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of May 2024, at
Dipolog City.

ROLAND B. LADERA
(Affiant)
BFP ID#91306157
With photo

SUBSCRIBED AND SWORN to before me this ___ day of May 2024, at Dipolog City
showing his/her document of identity as indicated above.

Doc. No.

Page No.

Book No.

Series of 2024
 ABDUL MINDOON LUMBOS
(Affiant)
PNP ID#18D110382
Expiry Date: 8/23/2021

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2020, at Dipolog City.
Republic of the Philippines
Department of Interior and Local Government
BUREAU OF FIRE PROTECTION
REGIONAL OFFICE IX
BFL Building, Fernan Street, Palmera, San Pedro, Zamboanga City
Email address: bfp9.rias@yahoo.com

MEMORANDUM

FOR : FSUPT
(Attn: OIC, PARMU)

FROM : Pat Carlos C Gonzales Jr.

SUBJECT : EXPLANATION

DATE : February 1, 2024

This has reference to the Memorandum relative to my SALN with unsigned portion of my spouse.

Truthfully, my spouse and I have been separated for a long time period already. We have not seen
each other for quite sometime already because, I heard from my mother-in-law, she is working in
Cagayan de Oro City.

I have filed a petition for declaration of nullity of our marriage which is pending right now at Regional
Trial Court- Branch 7 of Dipolog City, docketed as Civil Case No. 7403.

I was not able to procure her signature because we are not talking to each other. Despite my several
attempts to reach out with her she was not responsive and even yelled at me.
My only connection with her pertains to our child and I could come to her mother’s house everytime I
have matters to discuss relating to our child. But sadly, I am able to talk with her mother only because
she is not living there anymore.

Despite my earnest efforts but it was no avail

Thus, I was not able and am not able to secure her signature in my SALN.

I hope this explanation will warrant and suffice to support my SALN and accept my submission.

Respectfully submitted.

Carlos Calisas Gonzales Jr.

Patrolman

Republic of the Philippines

NATIONAL POLICE COMMISSION
PHILIPPINE NATIONAL POLICE, POLICE REGIONAL OFFICE 9
ZAMBOANGA DEL NORTE POLICE PROVINCIAL OFFICE
ROXAS MUNICIPAL POLICE STATION
Pres. Manuel A. Roxas, Zamboanga del Norte

MEMORANDUM

FOR : Provincial Director, ZNPPO

(Attn: OIC, PARMU)

FROM : Pat Carlos C Gonzales Jr.

SUBJECT : EXPLANATION

DATE : February 1, 2024

This has reference to the Memorandum relative to my SALN with unsigned portion of my spouse.

Truthfully, my spouse and I have been separated for a long time period already. We have not seen
each other for quite sometime already because, I heard from my mother-in-law, she is working in
Cagayan de Oro City.

I have filed a petition for declaration of nullity of our marriage which is pending right now at Regional
Trial Court- Branch 7 of Dipolog City, docketed as Civil Case No. 7403.
I was not able to procure her signature because we are not talking to each other. Despite my several
attempts to reach out with her she was not responsive and even yelled at me.

My only connection with her pertains to our child and I could come to her mother’s house everytime I
have matters to discuss relating to our child. But sadly, I am able to talk with her mother only because
she is not living there anymore.

Despite my earnest efforts but it was no avail

Thus, I was not able and am not able to secure her signature in my SALN.

I hope this explanation will warrant and suffice to support my SALN and accept my submission.

Respectfully submitted.

Carlos Calisas Gonzales Jr.

Patrolman

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT

I, CHARLEMAGNE C. SEVILLA, of legal age, Filipino, married, with office address of Sevilla
Power Enginering & Services, Tomas Claudio St., Dipolog City, Zamboanga del Norte after having
been duly sworn in accordance with law, hereby depose and state:

That I am the proprietor of Sevilla Power Engineering & Services;

That the abovenamed company is engaged in construction business;

That I know the complainants in this case of SRABIX-03-00011-2024 namely: Richard Teodosis,
Joven Jumawan, Fredie Arias, Arnulfo Arias, and Roland Mapute;

That all of the complainants were perennial absentees at the construction site of the company;

That from time to time, they incurred absences however the company just tolerated it because we need
laborers and employees at the construction site;

That there were times that these employees went absent for weeks but we just let it pass because we
needed their services;

That recently, they went absent again without notice except Roland Mapute who told us that he
resigned from the company because his former boss asked him to work for him so he resigned;

That their absences became normal to us that when they returned to work we accepted them without
question;

That we were just surprised that they went to the Labor when it was them who went AWOL;

That I still consider them as employees because they were not dismissed or terminated by the company;

That I hereby attest that it is not true that they were dismissed as they were not terminated in any way;
That as regards to their 13th month pay, it is already added to their daily wage because the nature of our
project does not go beyond one(1) year or it usually has a timeframe of six(6) months or even less so
we already added the 13th month pay in their daily wage.

That I am executing this Affidavit to attest to the truth of the foregoing statements.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of May 2024, at Dipolog
City.

CHARLEMAGNE C. SEVILLA
(Affiant)
Valid ID#_______________
With photo

SUBSCRIBED AND SWORN to before me this ___ day of May 2024, at Dipolog City showing
his/her document of identity as indicated above.

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

We: MARY LOYD B. SOLATORIO and FLORAPIS B. SOLATORIO, both of legal

age, both Filipinos, single and married, respectively, both residents of
Sta.Isabel, Dipolog City, after having been duly sworn in accordance with
law, hereby depose and state:
That we were the holders and possessors of a certificate of time deposit
with account number 20A002946 issued by Zamboanga del Norte
Cooperative Bank(ZNCoop Bank);

That recently, while we were trying to look for the said Certificate from
where we kept it, we found out that the ZNCoop Bank Certificate of time
deposit was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, we
considered it as totally lost;

As such, we are executing this Affidavit of Loss to attest to the truth of the
foregoing statements and for the purpose of attesting to the loss of the said
ZNCoop Bank certificate of time deposit.

IN WITNESS WHEREOF, we have hereunto affixed our signatures this ___ day
of __________ 2024, at Dipolog City.

FLORAPIS B. SOLATORIO MARY LOYD B. SOLATORIO

(Affiant) (Affiant)
Phil.ID#5732-7849-1294-6853 VIN#7202-0210A-
G0790MBS20000
With Photo With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at

Dipolog City.

Doc No. _____

Page No. _____
Book No. ____
Series of 2024
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT

We: ROBERTO P. BASTILLADA and TITO B. SOTILLO, both of legal age, both Filipinos, both
married, both residents of Olingan, Dipolog City, Zamboanga del Norte after having been duly sworn
in accordance with law, hereby depose and state:

That I am Foremen of Sevilla Power Engineering & Services, owned by Charlemagne C. Sevilla;

That the abovenamed company is engaged in construction business;

That we are responsible in supervising the employees of the abovenamed company at the construction
site;

That we know the complainants in this case of SRABIX-03-00011-2024 namely: Richard Teodosis,
Joven Jumawan, Fredie Arias, Michael Tabancura, Arnulfo Arias, and Roland Mapute;

That all of the complainants were perennial absentees at the construction site of the company;

That we usually reprimanded them for being absent at the construction site at their convenience

That from time to time, they incurred absences however the company just tolerated it because we need
laborers and employees at the construction site;

That there were times that these employees went absent for weeks but we just let it pass because we
needed their services;

That recently, they went absent again without notice except Roland Mapute who told us that he
resigned from the company because his former boss asked him to work for him so he resigned;

That their absences became normal to us that when they returned to work we accepted them without
question;

That we were just surprised that they went to the Labor when it was them who went AWOL and we
still considered them as employees as we did not dismiss them or terminate them;

That it is not true that they were dismissed;

That we are executing this Affidavit to attest to the truth of the foregoing statements.

IN WITNESS WHEREOF, we have hereunto affixed our signatures this ___ day of April 2024, at
Dipolog City.

ROBERTO P. BASTILLADA TITO B. SOTILLO

(Affiant) (Affiant)
Drivers License#J01-23-006254 Drivers License#J01-18-007097
With photo With photo

SUBSCRIBED AND SWORN to before me this ___ day of April 2024, at Dipolog City showing
his/her document of identity as indicated above.
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT

I, NORMAN S. GO, of legal age, Filipino, married, a resident of Victoria Country Homes, Obay,
Polanco, Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose
and state:

That I am the Timekeeper of Sevilla Power Engineering & Services, owned by Charlemagne C.
Sevilla;

That the abovenamed company is engaged in construction business;

That I am responsible in recording and checking the attendance of employees of the abovenamed
company;

That I know the complainants in this case of SRABIX-03-00011-2024 namely: Richard Teodosis,
Joven Jumawan, Fredie Arias, Arnulfo Arias, and Roland Mapute;

That all of the complainants were perennial absentees at the construction site of the company;

That from time to time, they incurred absences however the company just tolerated it because we need
laborers and employees at the construction site;

That there were times that these employees went absent for weeks but we just let it pass because we
needed their services;

That recently, they went absent again without notice except Roland Mapute who told us that he
resigned from the company because his former boss asked him to work for him so he resigned;

That their absences became normal to us that when they returned to work we accepted them without
question;

That we were just surprised that they went to the Labor when it was them who went AWOL;

That we still considered them as employees because they were not dismissed or terminated by the
company;

That it is not true that they were dismissed;

That I am executing this Affidavit to attest to the truth of the foregoing statements.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of April 2024, at
Dipolog City.

NORMAN S. GO
(Affiant)
Philippine ID#2459-0617-8196-0841
With photo

SUBSCRIBED AND SWORN to before me this ___ day of April 2024, at Dipolog City showing
his/her document of identity as indicated above.
DOC.NO.

PAGE NO.

BOOK NO.

SERIES OF 2024

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, CINDERELLA A. DY, of legal age, Filipino, single, a resident of 549 Noli Me Tangere St., Dapitan
City, Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and
state:

That I was holder and possessor of a driver’s license issued by Land Transportation Office(LTO),.

That on April 25, 2024, I discovered that the said driver’s license ID was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said driver’s license issued by LTO.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of April 2024, at
Dipolog City.

CINDERELLA A. DY
(Affiant)
J01-01-035404
With photo

SUBSCRIBED AND SWORN to before me this ___ day of April 2024, at Dipolog City showing
his/her document of identity as indicated above.

DOC.NO.
PAGE NO.

BOOK NO.

SERIES OF 2024

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, JAYMIKE L. MIRAFUENTES, of legal age, Filipino, single, a resident of Anastacio,

Polanco, Zamboanga del Norte after having been duly sworn in accordance with
law, hereby depose and state:

That I was holder and possessor of a driver’s license issued by Land

Transportation Office(LTO), National Identification Card issued by Philippine
Statistics Authority(PSA) and Philhealth card issued by Philippine Health Insurance
Corporation(PHIC).

That on April 16, 2024, I discovered that my wallet containing my said driver’s
license ID, national ID and Philheath ID was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it
as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
statements and for the purpose of attesting to the loss of the said driver’s license
issued by LTO, national ID issued by PSA and Philhealth ID issued by PHIC.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of April
2024, at Dipolog City.

JAYMIKE L. MIRAFUENTES
(Affiant)
Valid ID#________________________
With photo

SUBSCRIBED AND SWORN to before me this ___ day of April 2024, at Dipolog City.
DOC.NO.

PAGE NO.

BOOK NO.

SERIES OF 2024

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF CIVIL STATUS & NAME OF SPOUSE

WE: MERLINDA B. SABANAL, married; ROLANDO F. BALATE, married;

LEVILLA B. LIMBAGA, married; JUNILO F. BALATE, married and SOLEDAD F.
BALATE, single, all Filipinos, all of legal age, all residents of Lux, Gutalac,
Zamboanga del Norte after having been duly sworn in accordance with law,
hereby depose and state:

That in the settlement of estate of late Soledad F. Balate and Pilar F. Balate,
our statuses are indicated but name of respective spouses for married are
not indicated;

That we hereby declare that MERLINDA B. SABANAL is married to Marlon

Sabanal; ROLANDO F. BALATE is married to Josephine Lacquio; LEVILLA B.
LIMBAGA is married to Jose Limbaga; JUNILO F. BALATE is married to Norma
Oriola; and SOLEDAD F. BALATE is not married thus she has a civil status of
sinlge;

As such, we executing this Affidavit to attest to the truth of the foregoing

statements.

IN WITNESS WHEREOF, we have hereunto affixed our signatures this ___ day
of __________ 2024, at Dipolog City.

MERLINDA B. SABANAL, ROLANDO F. BALATE, LEVILLA B. LIMBAGA,,

SOLEDAD F. BALATE
Rep by:

JUNILO F. BALATE
(Affiant)
Drivers License#J05-10-001058
With phot
SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at
Dipolog City.

Doc. No.__
Page No.__
Book No.__
Series of 2024

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, HANS R. LABISIG, of legal age, Filipino, married, a resident of Estaka, Dipolog City, Zamboanga del
Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am the holder and possessor of original copies of approved survey plan and technical
descriptions of Lot Nos. 286 & 287, Pcs-09-004088 for parcel of land located Poblacion, Dapitan City.

That I kept the Approved Survey and it attachements but those were lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said Approved Survey and Technical Descriptions.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2024, at
Dipolog City.

HANS R. LABISIG
(Affiant)
Valid ID#____________
With photo
SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2024

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, BEBIE CLAIRE CAPALAC RENACIA, of legal age, Filipino, married, a resident of West Poblacion, Rizal,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am the sibling of Charlie C. Renacia, a graduate of Dipolog School of Fisheries, Dipolog City with
the baccalaureate course of BS HRM;

That I was holder and possessor of my brother’s Diploma as a graduate of said school;

That recently my brother asked from me the original copy of his Diploma however it was lost, and
could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said document.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2024, at
Dipolog City.
 BEBIE CLAIRE CAPALAC RENACIA
(Affiant)
PhilPost ID#PRNM83220124406P
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at Dipolog City showing
his/her document of identity as indicated above.

Doc. No.

Page No.

Book No.

Series of 2024

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, CHRISTOPHER WAYNE SPANGLER, of legal age, American citizen, single, a

resident of Tabuk tulay, Minaog, Dipolog City, Zamboanga del Norte after
having been duly sworn in accordance with law, hereby depose and state:

That I was a holder and possessor of a United States of America Passport

with Number 548712414 issued by the United States of America;

That last week, I discovered that my said passport was lost;

That I tried to look for it yet it was futile;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
passport.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2024, at Dipolog City.

CHRISTOPHER WAYNE SPANGLER

(Affiant)
Philippine ACR No.G2402010916TV
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at

Dipolog City showing his/her document of identity as indicated above.

Doc. No.___

Page No.___

Book No.___

Series of 2024
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I:JUNRY L. JAMO, of legal age, Filipino, single/married, a resident of Poblacion

South, Pinan, Zamboanga del Norte after having been duly sworn in
accordance with law, hereby depose and state:

That I was a holder and possessor of original copy of Official Receipt(OR) for
the registration of my vehicle with Plate No.612JZO, CR No.47685459-3,
Make: Honda; Engine No.KF46E7089901; Chassis No.MH1KF4674MK089790
issued by the Land Transportation Office(LTO);

That recently, I discovered that my said OR was lost;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
OR.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2024, at Dipolog City.

JUNRY L. JAMO

(Affiant)

PRC ID#0185026
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at

Dipolog City showing her document of identification as indicated above.

Doc. No.

Page No.

Book No.

Series of 2024
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

JOINT AFFIDAVIT

We: CARMELITA E. BELARMINO and VINCENT A. OCAY, both Filipinos, both of legal
age, married, and both residents of Silano, Piǹan, Zamboanga del Norte after
having been duly sworn in accordance with law, hereby depose and state:

That I: CARMELITA E. BELARMINO, am an Indigenous People Mandatory

Representative(IPMR) of the Barangay Council of Silano, Piǹan, Zamboanga del
Norte while I: VINCENT A. OCAY, am the Sanggunian Kabataan Chairperson of
Barangay Council of Silano, Piǹan, Zamboanga del Norte;

That we are ex-officio members of Barangay Council of Silano, Piǹan, Zamboanga

del Norte;

That we are incumbent members of the said barangay council;That the Barangay
Council has ten(10) members including the Punong Barangay;

That we hereby attest that on December 4, 2023 there was a first session in our
Barangay Council with EVELYN P. HAMOY, SEVELINA B. PROTACIO, TITO A.
DUHAYLUNGSOD and HENRY B. ANDUS attended and participated the session as
newly elected Sangguniang Barangay Kagawad;

That we hereby attest that in the said session, EVELYN P. HAMOY was elected by
the majority as Chairperson of Committee on Appropriations Budget and Finance
while SEVELINA B. PROTACIO was elected by majority as Chairperson on
Committee on Senior Citizens Affairs. That it is not true that Rolly Basong was
elected as Chairperson of Committee on Appropriations Budget and Finance and it
is not true that Norberto Gadayan was elected as Chairperson on Committee on
Senior Citizens Affairs;

That further we received a memorandum from Punong Barangay Jenelyn Jumilid

that there was no session held on December 18, 2023 and thus, there was no
session on the said date;

That we did not attend the said session and we attest that six of us namely:
EVELYN P. HAMOY, SEVELINA B. PROTACIO, TITO A. DUHAYLUNGSOD, HENRY B.
ANDUS, and us did not attend a session on December 18, 2018 due to the
memorandum; That however we signed a minutes of meeting on said date
because Punong Barangay Jenelyn Jumilid told us that we would receive our
honoraria if we signed;

That we read and understand this affidavit, explained in Visayan language, and
we voluntarily execute this affidavit;

That as such we are executing this Affidavit to attest to the truth of the foregoing
statements.

IN WITNESS WHEREOF, we have hereunto affixed our signatures this ___ day of
__________ 2024, at Dipolog City.

CARMELITA E. BELARMINO VINCENT A. OCAY

Affiant Affiant
Philhealth ID#8758-4063-7450-8209 Drivers License#J01-20-006238

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at Dipolog
City.

Doc. No.__ Book No._____

Page No.__ Series of 2024
Book No.__
Series of 2024

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF CIVIL STATUS & NAME OF SPOUSE

I, JANET E. ESTRADA, Filipino, of legal age, married, and a resident of

Dipolog City, Zamboanga del Norte after having been duly sworn in
accordance with law, hereby depose and state:
That in the settlement of estate, my status and name of my spouse are not
indicated;

That my civil status is married;

That the name of my spouse is Cornelio B. Estrada;

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

statements.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2024, at Dipolog City.

JANET E. ESTRADA
(Affiant)
Valid ID#__________
With phot

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at

Dipolog City.

Doc. No.__
Page No.__
Book No.__
Series of 2024

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF CONFIRMATION AS WITNESS

I:SIMPLICIO N. YANDOG, of legal age, Filipino, married, a resident of Dicayas,
Dipolog City, Zamboanga del Norte after having been duly sworn in
accordance with law, hereby depose and state:

That I am one of the witnesses of Affidavit of Quitclaim and/or Formal

Waiver of Rights subscribed and sworn to before David G. Amores,Jr., Land
Management Inspector of DENR;

That in the said Affidavit of Quitclaim and/or Formal Waiver of Rights,

IGNACIO M. MORANDARTE and TOMASA MAWILI waived their rights over a
parcel of land known as Lot No.3150, Cad-85(Portion) bounded on the N.,by
Lot 921, Cad-85, on the E.,by property claimed by Lorenzo Noel;on the S.,by
Existing Barangay Road and on the W., by portion of Lot 3150, Cad-85
containing an area of Six Hundred Fifty Two(652) square meters, more or
less, in favor of HUBERT M. MORANDARTE;

That I witnessed the said transaction and I affirm that Ignacio M. Morandarte
and Tomasa Mawili received the amount of Twenty
Thousand(P20,000.00)Pesos and they waived their ownership rights over
the said parcel of land in favor of Hubert M. Morandarte on 10 March 2006
at CENRO Office, Dipolog City;

That the parties voluntarily and freely executed the said affidavit before
David G. Amores,Jr and I confirm that Hubert M. Morandarte became the
owner of the said parcel of land since then and until now.

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

statements and for other legal purposes.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2024, at Dipolog City.

SIMPLICIO N. YANDOG

(Affiant)

Valid ID#_____________
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at

Dipolog City showing her document of identification as indicated above.

Doc. No.

Page No.

Book No.
Series of 2024

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, JOCELYN KIM R. CARABIO, Filipino, of legal age, married, and a resident of

Turno, Dipolog City, Zamboanga del Norte after having been duly sworn in
accordance with law, hereby depose and state:

That I was a holder and possessor of receipt issued by Cebuana Lhuillier-

Dipolog 1 Branch for pawned jewelry Necklace Cont. Pendant in the amount
of P10,422.00 under Pawnticket No.50303NP005289, dated December 28,
2023;

That recently, my said receipt was lost;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
receipt.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2024, at Dipolog City.

JOCELYN KIM R. CARABIO

(Affiant)
PRC ID#0590906-Nurse
With phot

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at

Dipolog City.

Doc. No.__
Page No.__
Book No.__
Series of 2024
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I:ALEX G. PANDAN, of legal age, Filipino, single/married, a resident of San

Antonio, Polanco, Zamboanga del Norte after having been duly sworn in
accordance with law, hereby depose and state:

That I was a holder and possessor of Certificate of Registration of my vehicle

with Plate No.2302 JI issued by the Land Transportation Office(LTO) with
Official Receipt(OR) registered in the name of Roseller Gerzon;

That recently, I discovered that my said certificate of registration with OR

was lost;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
certificate of registration with OR.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2024, at Dipolog City.

ALEX G. PANDAN

(Affiant)

Valid ID#_____________
With photo
SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at
Dipolog City showing her document of identification as indicated above.

Doc. No.

Page No.

Book No.

Series of 2024

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ROSAHIEN JAN MEDINA AMIGABLE, of legal age, Filipino, married, a

resident of Sitio Look, Barangay Dos, Katipunan, Zamboanga del Norte after
having been duly sworn in accordance with law, hereby depose and state:

That I was a holder and possessor of a Philippine Passport issued by the

Department of Foreign Affairs;

That on December 4, 2021, I discovered that my passport was lost;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
passport.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2024, at Dipolog City.

ROSAHIEN JAN MEDINA AMIGABLE

(Affiant)
 Philhealth ID#02-026575033-9
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at

Dipolog City showing his/her document of identity as indicated above.

Doc. No.___

Page No.___

Book No.___

Series of 2024

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, MARY JOY D. DUHAYLUNGSOD, of legal age, Filipino, single, a resident of Silano, Pinan, Zamboanga
del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am aunt of DUBLIN MANUEL B. CALAPE, a student of DMC College Foundation, Inc.(DMC)

That he was a holder and possessor of a School Identification(ID) Card issued by said schoold for
being its student.

That recently, while I was trying to look for the said school ID, then I found out that his school ID was
lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said School ID.
IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of ______ 2024, at Dipolog
City.

MARY JOY D. DUHAYLUNGSOD

(Affiant)
TIN#715-913-482
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at Dipolog City.

Doc. No.
Page No.
Book No.
Series of 2024

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF CIVIL STATUS

We: EDWARD L. ONG; RICKSHAW L. ONG; MAVERICK L. ONGl and SHANE L.

ONG,all of legal age,all Filipinos, all single, all residents of South Mapang,
Rizal, Zamboanga del Norte after having been duly sworn in accordance
with law, hereby depose and state:

That we have all civil staus of “SINGLE”.

That we are executing this Affidavit attest to the truth of the foregoing
statements.

IN WITNESS WHEREOF, we have hereunto affixed our signatures this ___ day
of __________ 2024, at Dipolog City.

EDWARD L. ONG
(Affiant)
Valid ID#___________________
With photo

RICKSHAW L. ONG
(Affiant)
Valid ID#_________________________
With photo

MAVERICK L. ONG
(Affiant)
Valid ID#________________________
With photo

SHANE L. ONG
(Affiant)
Valid ID#_______________
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at

Dipolog City.

Doc. No.___

Page No.___

Book No.___

Series of 2024
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF WITHDRAWAL OF APPLICATION OF TITLE

I:ASUNCION BANGOT-AMBA, of legal age, Filipino, married, a resident of

Poblacion, Rizal, Zamboanga del Norte after having been duly sworn in
accordance with law, hereby depose and state:

That I am the child of late DIONISIO BANGOT;

That my late father DIONISIO BANGOT is the declared

Administrator/Beneficial User of a parcel of land more particularly described
as follows:

“A parcel of land known as Cadastral Lot No.9417 registered in the name of

Heirs of Agapito Lawagon located Hinawanan, Loay, Bohol containing an ara
of 6,207 square meters, more or less covered by Tax Declaration No.2016-
28-011-00065 issued by Assessor of Bohol.”

That my father did not receive any title relative to the application of patent
or any titling mode of transfer over the said parcel of land;

That thus, I am respectfully informing the Honorable CENRO that I am

withdrawing the application for title of my late father over the said parcel of
land;

That I am executing this Affidavit to attest to the truth of the foregoing

statements and to effect of withdrawal of application of title over Cadastral
Lot No.9417 since there was no title received by my late father or any other
persons in his behalf.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2024, at Dipolog City.

ASUNCION BANGOT-AMBA

(Affiant)

Valid ID#_______________________
With photo
SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at
Dipolog City showing her document of identification as indicated above.
Doc. No.

Page No.

Book No.

Series of 2024

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I:FLORILYN R. DECIERDO, of legal age, Filipino, widow, a resident of San

Antonio, Manukan, Zamboanga del Norte after having been duly sworn in
accordance with law, hereby depose and state:

That I am the Acting Treasurer of LGU-Manukan, Zamboanga del Norte;

That after the death of the Municipal Treasurer, I looked for the original
copies of the Certificate of Registration and Official Receipt of motor vehicle
with Engine No.YD25081354B, Chassis No.JN1LC4E26Z0017504, CR
No.41563693-3 and its official receipr

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
certificate of registration with OR.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2024, at Dipolog City.

FLORILYN R. DECIERDO

(Affiant)
 LGU-Manukan Employee ID#1091-02
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at

Dipolog City showing her document of identification as indicated above.

Doc. No.

Page No.

Book No.

Series of 2024

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF DENIAL

I, CRESELITO D. BARRIOS, of legal age, Filipino, married, and presently residing of Brgy.
Sta. Cruz, Dapitan City, Zamboanga del Norte after having been duly sworn in accordance with
law, hereby depose and state:

That I was the former Municipal Assessor and former Municipal Treasurer of Municipality of
La Libertad, Zamboanga del Norte;

That there was Deed of Absolute Sale dated May 18, 1995 notarized by Atty. Jesus Napigquit
of Dipolog City per Notarial Register with Doc. No.4227, Page No. 5, Book No.XII, Series of
1995 wherein I was one of the two(2) witnesses;

That the said sale of land pertained to a portion of 300 square meters of parcel of land located at
Poblacion, La Libertad, Zamboanga del Norte covered by Tax Declaration No.2382;

That there was really no sale over the said portion of parcel of land from Spouses Ellen Yap Yu
and Francisco Yu in favor of Spouses Abundancia Baid and Guillermo Calsado because
Spouses Ellen Yap Yu and Francisco Yu did not sign the said deed of absolute sale;

That it was Guillermo Calsado who signed the said deed of absolute sale and pretended to be
the sellers during the appearance before the lawyer;
That Guillermo Calsado asked me to be a witnessed after we had a drinking session in La
Libertad;

That Guillermo Calsado told me that they were really the owner over the said portion of land
because it was given to them by the previous owner although they could sign the deed of
absolute sale or donation because they were not in La Libertad at that time;

That as a former Municipal Assessor, Guillermo Calsado asked me ahead to register the portion
of 300 square meters in their favor in our records;

That I am executing this to certify that the said deed of absolute sale did not really happen and
there was no sale over the said 300 square meters of land;

That I am executing this Affidavit to attest to the truth of the foregoing statements and for the
purpose of attesting the denial of the deed of absolute sale.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________
2024, at Dipolog City.

CRESELITO D. BARRIOS
(Affiant)
Valid ID#_________________________
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at Dipolog City
showing his/her document of identity as indicated above.

Doc. No

Page No.

Book No.

Series of 2024
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, MARGIE T. LAGORRA, of legal age, Filipino, married, with address of Daanglungsod, Katipunan,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I was possessor of receipts for the Documentary Stamp Tax Return and Capital Gains Tax Return
issued by the Bureau of Internal Revenue for a portion of parcel of land covered by OCT No.P-5490
located at Daanglungsod, Katipunan, Zamboanga del NorteI purchased from Isabelita Reganion.

That recently, while I was trying to arrange several office documents and locating the said receipt, but
it was lost and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said receipts.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2024, at
Dipolog City.

MARGIE T. LAGORRA
(Affiant)
VIN#7203-0039A-G2083MTL20000
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2024
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I:ROLANDO NITORA CHIU, of legal age, Filipino, married, a resident of La

Union, La Libertad, Zamboanga del Norte after having been duly sworn in
accordance with law, hereby depose and state:

That I was a holder and possessor of Official Receipt(OR) with No.

2264591663 issued on November 24, 2022 of motor vehicle with Plate
Number 543KVN, Make: Skygo, CR No.46165537-5 issued by the Land
Transportation Office(LTO);

That recently, I discovered that my said OR was lost;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
OR.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2024, at Dipolog City.

ROLANDO NITORA CHIU

(Affiant)

Drivers License#J01-98-027298
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at

Dipolog City showing her document of identification as indicated above.

Doc. No.

Page No.

Book No.

Series of 2024
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ELMER GALAURA YAROT, of legal age, Filipino,married, a resident of

Bauno, Gulayon, Dipolog City, Zamboanga del Norte after having been duly
sworn in accordance with law, hereby depose and state:

That I was a holder and possessor of a Katipunan Rural Bank Passbook

issued by the same bank;

That recently, I found out that my said Passbook was lost;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
Passbook.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2024, at Dipolog City.

ELMER GALAURA YAROT

(Affiant)
 Voters ID#7202-0171A-E1867EGY20000-5
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at

Dipolog City.

Doc. No.___

Page No.___

Book No.___

Series of 2024

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, LOVELY THERESE BAYLON PALUCA, of legal age, Filipino, married, a resident of Central Barangay,
Dipolog City, Zamboanga del Norte after having been duly sworn in accordance with law, hereby
depose and state:

That I was a holder and possessor of Diploma issued by Jose Rizal Memorial State University-Dipolog
City Campus after I graduated with baccalaureate degree of Bachelor of Science in Hotel and
Restaurant Management(BSHRM) sometime in year 2011;.

That recently, while I was trying to locate the said diploma, but it was lost and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said Diploma.
IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2024, at
Dipolog City.

LOVELY THERESE BAYLON PALUCA

(Affiant)
PRC ID#1537145 valid until 8/4/2026
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at Dipolog City.

Doc. No

Page No.

Book No.

Series of 2024

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, GEMMA INDUS BATION, of legal age, Filipino, married, a resident of Sangkol, Dipolog City,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a Coordinator of Juander Radyo Loyalista;

That recently, my weekly Collection form for December 2023, but it was lost and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;
As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
all legal intents and purposes.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2024, at
Dipolog City.

GEMMA INDUS BATION

(Affiant)
COMELEC ID No. 7202-0299A-L2370GIB20000-0

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at Dipolog City.

Doc. No

Page No.

Book No.

Series of 2024

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ELFFIE FACTURAN CARCALLAS, Filipino, of legal age, married, and a

resident of Dampalan, Dapitan City, Zamboanga del Norte after having
been duly sworn in accordance with law, hereby depose and state:

That I was a holder and possessor of receipts issued by Cebuana Lhuillier-

Dipolog 1 Branch for pawned jewelries, to wit:
1.

Pawnticket No.:50303NP001316 Jewelry Pawned: Necklace with

Pendant 11.9 grams

Amount:P31,237.00 Date of Issue/Loan:November 26,

2023
2.

Pawnticket No.:50303NP001317 Jewelry Pawned: Necklace with

 Pendant 8.6 grams

Amount:P22,575.00 Date of Issue/Loan:November 26,

2023
3.

Pawnticket No.:50303NP001318 Jewelry Pawned: Necklace 6.9 grams

Amount:P18,112.00 Date of Issue/Loan:November 26,

2023

That recently, my said receipts were lost;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
receipts.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2024, at Dipolog City.

ELFFIE FACTURAN CARCALLAS

(Affiant)
PhilPost ID#PRNM83180626789P
With phot

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at

Dipolog City showing his/her document of identity with number indicated
above.

Doc. No.__
Page No.__
Book No.__
Series of 2024

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LATE REPORT

I, MICHAEL DOUGLAS DEGRAZIA, of legal age, American, married, with Philippine address of 012
Purok Bayabas, Sangkol, Dipolog City, Zamboanga del Norte after having been duly sworn in
accordance with law, hereby depose and state:
That I am holder of Alien Certificate of Registration(ACR) issued by the Bureau of Immigration
regarding my Probationary Residency Visa;

That relative to my ACR and/or Visa, I was required to report on regular/timely manner at the Bureau
of Immigration;

That however I was not report regularly to the Bureau of Immigration and able to renew my ACR
and/or Visa timely on the reason that the agent I engaged to process my ACR and/or Visa was not
able to inform the undersigned the requirement to report timely at the Bureau of Immigration and
the said agent also suddenly resigned from our engagement. That as a result I was not able to report
and renew my ACR and/or Visa at the Bureau of Immigration;

That I intend to renew my ACR and/or Visa and comply to all regulatory requirements relative to my
stay in the Philippines on the reason that my spouse and child are living here in the Philippines;

As such, I am executing this Affidavit to attest to the truth of the foregoing statements in order to
justify my late report to the Bureau of Immigration and/or renew my ACR and/or Visa.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2024, at
Dipolog City.

MICHAEL DOUGLAS DEGRAZIA

(Affiant)
Driver’s License#J01-22-304967
Valid Until 01/01/2027
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at Dipolog City showing
his/her document of identity as indicated above.
Doc. No.__
Page No.__
Book No.__
Series of 2024
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ARIMATEA P. ESTRELLA, of legal age, Filipino, widow, with address of Barra, Dipolog City,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am the business owner of a business with Business Name “ RA Pharmacy and Medical Supplies
Distribution” situated at Bonifacio St., Barra, Dipolog City, Zamboanga del Norte. The said business is
registered with Department of Trade and Industry(DTI) and issued a DTI registration permit.

That recently, while I was trying to look several office documents and locating the said DTI
registration, but it was lost and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said DTI Registration.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2024, at
Dipolog City.

ARIMATEA P. ESTRELLA
(Affiant)
Phil.ID#4902-9831-6537-5473
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at Dipolog City showing
his/her document of identity as indicated above.
Doc. No.__
Page No.__
Book No.__
Series of 2024
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I:RENATO JARO IDJAO, of legal age, Filipino, married, a resident of Turno,

Dipolog City, Zamboanga del Norte after having been duly sworn in
accordance with law, hereby depose and state:

That I was a holder and possessor of Certificate of Registration of my vehicle

with Engine No.KWY00E154109, Chassis No.KWY00154104, Plate No.3313JI
issued by the Land Transportation Office(LTO) with Official Receipt(OR);

That recently, I discovered that my said certificate of registration with OR

was lost;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
certificate of registration with OR.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2024, at Dipolog City.

RENATO JARO IDJAO

(Affiant)

OSCA ID#22032-Dipolog City

With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at

Dipolog City showing her document of identification as indicated above.

Doc. No.

Page No.

Book No.

Series of 2024
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I:MINROSE BAYRON OGOC, of legal age, Filipino, single, a resident of

Minaog, Dipolog City, Zamboanga del Norte after having been duly sworn in
accordance with law, hereby depose and state:

That I was a holder and possessor of a cel=lular phone with brand Oppo
CPH1909 model;

That it contained all the applications and other files related to my person
and professional work;

That on February 19, 2024 around 7 in the evening, I discovered that my

said cellular phone was lost;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
cellular phone.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2024, at Dipolog City.

MINROSE BAYRON OGOC

(Affiant)

PRC ID#0094534-Civil Engineer

With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at

Dipolog City showing her document of identification as indicated above.

Doc. No.

Page No.

Book No.

Series of 2024
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT

I, MARBIN ALAP-AP TUBAT, of legal age, Filipino, single, a resident of Liyang, Dapitan City, Zamboanga
del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am the document owner of the following documents:

1. Diploma issued by Jose Rizal Memorial State University, Dapitan City Campus as graduate of
Bachelor of Secondary Education;

2. Transcript of Records issued by Jose Rizal Memorial State University, Dapitan City Campus;

3. Certificate issued by EFSET;

4. Certification dated 4th day of September 2023 issued by Department of Education;

5. TESOL CERTIFICATE;

That the abovesaid documents are faithful reproduction of the original copies issued by government
agencies of the Philippines.

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

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2023, at
Dipolog City.

MARBIN ALAP-AP TUBAT

(Affiant)
PRC ID#1403540 valid until 1/26/2024
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at Dipolog City showing
his/her document of identity as indicated above.

Doc. No.

Page No.

Book No.

Series of 2023
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, JOSE NIǸO REALISTA AYSON, of legal age, Filipino, married, a resident of

Purok Buli, Minaog, Dipolog City, Zamboanga del Norte after having been
duly sworn in accordance with law, hereby depose and state:

That I was a holder and possessor of a Philippine Passport issued by the

Department of Foreign Affairs;

That recently, I discovered that my passport was lost;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
passport.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2024, at Dipolog City.

JOSE NIǸO REALISTA AYSON

(Affiant)
Philippine ID#2643-0760-5972-0618
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at

Dipolog City showing his/her document of identity as indicated above.

Doc. No.___

Page No.___

Book No.___

Series of 2024
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, EDGAR M. AGAYAN, of legal age, Filipino, married, a resident of Obay, Polanco,

Zamboanga del Norte after having been duly sworn in accordance with law,
hereby depose and state:

That I was a holder and possessor of Technical Description documents for Lot
2330-F-4 under PSD-09-080007 for lot located at Sinaman, Dipolog City,
Zamboanga del Norte.

That recently while I was checking my file containing the said document so that I
could process titling over said land, I found out that the document was lost, and
could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it
as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
statements and for the purpose of attesting to the loss of the said technical
description for Lot 2330-F-4 and request for replacement of the same.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2024, at Dipolog City.

EDGAR M. AGAYAN

(Affiant)

Valid ID#__________

With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at Dipolog
City.
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I:GABRIELA BASCO RONQUILLO, of legal age, Filipino, married, a resident of

Bliss, Anastacio, Polanco, Zamboanga del Norte after having been duly
sworn in accordance with law, hereby depose and state:

That I was a holder and possessor of Drivers License with number

J0109000477 and its Original Copy of Official Receipt(OR) issued by the
Land Transportation Office(LTO);

That recently, I discovered that my said driver’s license and its original copy
of OR was lost;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
drivers license and original copy of OR.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2024, at Dipolog City.

GABRIELA BASCO RONQUILLO

(Affiant)

Phil. Passport#P9801533B
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at

Dipolog City showing her document of identification as indicated above.

Doc. No.

Page No.

Book No.

Series of 2024
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, CHAN DAVE M. FORTUITO, of legal age, Filipino, single, a resident of Turno, Dipolog City,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I was holder and possessor Certificate of Good Moral Character, PSA Birth Certificate and Form
137 or card issued ZNNHS-Annex Campus, Turno, Dipolog City;

That I discovered that the original copy of my PSA Birth Certificate, good moral and Form 137 were
lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said PSA Birth Certificate, good moral, and Form 137.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2024, at
Dipolog City.

CHAN DAVE M. FORTUITO

(Affiant)
JRMSU School ID#DC-22-A-00997
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at Dipolog City.

Doc. No.

Page No.

Book No.

Series of 2024
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ELEONOR S. TAMONAN, of legal age, Filipino, single/married, a resident of

Obay, Polanco, Zamboanga del Norte after having been duly sworn in
accordance with law, hereby depose and state:

That I was a holder and possessor of a Philippine Passport issued by the

Department of Foreign Affairs;

That recently, I discovered that my passport was lost;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
passport.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2024, at Dipolog City.

ELEONOR S. TAMONAN
(Affiant)
Drivers License#J01-20-006745
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at

Dipolog City showing his/her document of identity as indicated above.

Doc. No.___

Page No.___

Book No.___

Series of 2024
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, JOCELYN KIM R. CARABIO, Filipino, of legal age, married, and a resident of

Turno, Dipolog City, Zamboanga del Norte after having been duly sworn in
accordance with law, hereby depose and state:

That I was a holder and possessor of receipt issued by Cebuana Lhuillier-

Dipolog 1 Branch for pawned jewelry Necklace Cont. Pendant in the amount
of P10,422.00 under Pawnticket No.50303NP005289, dated December 28,
2023;

That recently, my said receipt was lost;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
receipt.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2024, at Dipolog City.

JOCELYN KIM R. CARABIO

(Affiant)
PRC ID#0590906-Nurse
With phot

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at

Dipolog City.

Doc. No.__
Page No.__
Book No.__
Series of 2024
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ZENEN PSYCHE GRACE S. GUTIERREZ, of legal age, Filipino, with address of Galas, Dipolog City,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I was possessor of Certificate of Registration as well as the ASK FOR RECEIPT document issued by
the Bureau of Internal Revenue under the business name of 18K Tailoring.

That recently, while I was trying to arrange several office documents and locating the said BIR
Certificate of Registration and ASK FOR RECEIPT, but it was lost and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said Original Copy of Certificate of Registration and ASK FOR
RECEIPT document.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2024, at
Dipolog City.

ZENEN PSYCHE GRACE S. GUTIERREZ

(Affiant)
TIN#928-978-025
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2024
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, STEPHEN PAUL F. PANIGSING, of legal age, Filipino, single/married, a resident of Mias, Katipunan,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I was a holder and possessor of Certificates of Stock Reported(CSR) for motor vehicle Kawasaki
with Engine No.DYXWNF28869, Chassis No.MD2A76BX4NWF72185 and Kawasaki with Engine
No.DYXWNH60407, Chassis No.MD2A76BXXPWH50605;

That recently, I discovered that my said CSRs were lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said CSRs and thereafter requesting replacement of the
same.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2024, at
Dipolog City.

STEPHEN PAUL F. PANIGSING

(Affiant)
Drivers License#J01-19-003124
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024 by above-named person
showing her document of identity as shown above, at Dipolog City.

Doc. No.

Page No.

Book No.

Series of 2024
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, JUAINE A. PESTAǸAS, of legal age, Filipino,single, a resident of Potungan,

Dapitan City, Zamboanga del Norte after having been duly sworn in accordance
with law, hereby depose and state:

That I was a holder and possessor of Technical Description document for Lot 7-D-2
under PSD-09-080327 for lot located at Bagacay, Sibutad, Zamboanga del Norte
covered by TCT No.T-79291.

That recently while I was checking my file containing the said document so that I
could process titling over said land, I found out that the document was lost, and
could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it
as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
statements and for the purpose of attesting to the loss of the said technical
description for Lot 7-D-2 and request for replacement of the same.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2024, at Dipolog City.

JUAINE A. PESTAǸAS

(Affiant)

Philhealth ID#14-201815936-7

With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at Dipolog
City.
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, CARYL MAE A. ANGGOT, of legal age, Filipino, married, a resident of Polanco, Zamboanga del Norte
after having been duly sworn in accordance with law, hereby depose and state:

That I was a holder and possessor of a Globe Sim card with number 639776014851;

That recently, I discovered that my said simcard was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said sim card and thereafter requesting replacement of the
same.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2024, at
Dipolog City.

CARYL MAE A. ANGGOT

(Affiant)
Philhealth No.14-201063639-5
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024 by above-named person
showing her document of identity as shown above, at Dipolog City.

Doc. No.
Page No.

Book No.

Series of 2024

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, GINA MARIA P. LIMBAGA, of legal age, Filipino, widow, a resident of

Olingan, Dipolog City, Zamboanga del Norte, after having been duly sworn
in accordance with law, hereby depose and state:

That I am a holder and possessor of a Policy Contract and Certificate of Full

Payment/Notice of Full Payment issued by Caritas Health Shield, Inc.;

That in recently, while I was trying to look for the said Policy Contract and
Certificate of Full Payment/Notice of Full Payment from my file where I kept
it, I found out that the documents were lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost;

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

foregoing statements and for the purpose of attesting to the loss of the said
Policy Contract, and Certificate of Full Payment/Notice of Full Payment
issued by Caritas Health Shield, Inc.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day

of____ 2024, at Dipolog City.

GINA MARIA P. LIMBAGA

(Affiant)
TIN#932-763-232
With Photo
SUBSCRIBED AND SWORN to before me this ___ day of ___2024, at Dipolog
City.

DOC. NO.

PAGE NO.

BOOK NO.

SERIES OF 2024

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, VIRGINIA B. LACAYA, of legal age, Filipino, married to Rodolfo Lacaya, resident of Sta.Filomena,
Dipolog City, Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and
state:

That I am the registered owner of a parcel of land, more particularly described as follows:

A parcel of land known as Lot No.656-B-3,Psd-09-014046, covered by Transfer Certificate of Title No.T-8699
situated at Central Barangay, Dipolog City, Zamboanga del Norte, containing an area of 55 square meters
issued by the Register of Deeds for Dipolog City.

That I was about to process the donation of my land in favor of my child so I tried to look for my owner’s copy
of the title, I could no longer find it;

That despite effort to recover the same but it was naught.

That I considered it as totally lost.

That I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for the purpose
of attesting to the loss of the said owner’s copy of Transfer Certificate of Title No.T-8699.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ____th day of _____________ 2024, at
Dipolog City.

VIRGINIA B. LACAYA
(Affiant)
OSCA ID#2129476-Dipolog City
With photo
SUBSCRIBED AND SWORN to before me this ___th day of _________ 2024, at Dipolog City showing the
document of identity as shown above.

DOC.NO. ______

PAGE NO.___

BOOK NO.___

SERIES OF 2024

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I:ZENAIDA C. EMPANG, of legal age, Filipino, widow, a resident of Relocation

Site, Olingan, Dipolog City, Zamboanga del Norte after having been duly
sworn in accordance with law, hereby depose and state:

That I am a collection officer of Zamboanga del Norte Medical Center,

Dipolog City, government hospital under the Provincial Government of
Zamboanga del Norte per Memorandum No.22-033D dated July 4, 2022;

That as a result, I am a custodian of Official Receipts(OR) or Accountable

Form No.51B;

That one of the ORs under my custody was OR No.0048326;

That on February 6, 2024, I was informed that OR No.0048326 was nowhere

to be found from the stub of receipts in my custody;

That I tried to look for the said OR but it was nowhere to be found;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
OR.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2024, at Dipolog City.
 ZENAIDA C. EMPANG

(Affiant)

ZNMC Employee ID#______________

With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at

Dipolog City showing her document of identification as indicated above.

Doc. No.

Page No.

Book No.

Series of 2024

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I:KEITZ HAROLD B. ATES, of legal age, Filipino, single, a resident of

Poblacion North, Polanco, Zamboanga del Norte after having been duly
sworn in accordance with law, hereby depose and state:

That I was a holder and possessor of Certificate of Registration of my vehicle

with Plate number KX8082 issued by the Land Transportation Office(LTO);

That recently, I discovered that my said certificate of regisration was lost;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
certificate of registration.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2024, at Dipolog City.

KEITZ HAROLD B. ATES

(Affiant)

BFP Employee ID#A19039

 With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at

Dipolog City showing her document of identification as indicated above.

Doc. No.

Page No.

Book No.

Series of 2024

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, DANILO J. TABA,JR, of legal age, Filipino,single/married, with office address

of Orix Metro Leasing & Finance Corporation, Echavez St.,, Dipolog City,
Zamboanga del Norte after having been duly sworn in accordance with law,
hereby depose and state:

That I am an employee of Orix Metro Leasing & Finance Corporation;

That one of our co-employee Mariel A. Kuan, the holder and possessor of a
check with number 2000001219 dated 02/07/2024 issued by Bigasan ni
Kambal under Account No.4130-70001237 at PNB-Liloy, Zamboanga del
Norte Branch in the amount of P93,309.00 issued to Orix Metro Leasing &
Finance Corporation;

That she left the company and I tried to look for the said check and ask from
Mariel Kuan but she could no longer recall where she kept it;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
check.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2024, at Dipolog City.

DANILO J. TABA,JR
(Affiant)
ORIX Employee ID#2408
 With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at

Dipolog City.

Doc. No.___

Page No.___

Book No.___

Series of 2024

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF
2.NANCY C. LAURQUE, of legal age, Filipino, married, resident of Poblacion North, Polanco, Zamboanga del
Norte

3.ROGER C. LAURQUE, of legal age, Filipino, married, a resident of Poblacion North, Polanco, Zamboanga
del Norte;

4. DANNIE C. LAURQUE, of legal age, Filipino, married, resident of Poblacion North, Polanco, Zamboanga
del Norte;

5. OSCAR C. LAURQUE, of legal age, Filipino, married, resident of Poblacion North, Polanco, Zamboanga del
Norte;
I, KAREN JANE E. MONDEJAR, of legal age, Filipino, married, a resident of Dwarf Santan, Gulayon,
Dipolog City, Zamboanga del Norte after having been duly sworn in accordance with law, hereby
depose and state:

That I was a holder and possessor of my Automated Teller Machine(ATM) card issued by Eastwest
Bank-Dipolog City Branch.

That recently, my said ATM card was lost;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said ATM card issued by Eastwest Bank-Dipolog City Branch.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2024, at
Dipolog City.

KAREN JANE E. MONDEJAR

(Affiant)
Drivers License #J01-20-006566 valid until 2025/06/04
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at Dipolog City showing
his/her document of identity as indicated above.

Doc. No.

Page No.

Book No.

Series of 2024
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, AUGUSTUS A. PIǸERO, of legal age, Filipino, married, a resident of Purok Nipa, Minaog,
Dipolog City, Zamboanga del Norte after having been duly sworn in accordance with law,
hereby depose and state:
That I am the registered owner of a firearm, described as follows:

MAKE KIND CALIBER SERIAL NO.

NORIN PISTOL 9MM 508137

That my said firearm was kept in my house in Minaog, Dipolog City however in January 2023
we experienced heavy flood and my house was flooded. That, after the flood subsided, I
looked for my said firearm however it was nowhere to be found;

That despite effort to recover the same but it was naught.

Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements
and for the purpose of attesting to the loss of the said firearms.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2024,
at Dipolog City.

AUGUSTUS A. PIǸERO

(Affiant)

OSCA Control No.2129473-Dipolog City

With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2024

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, DIANA MARIE A. SALIRING, of legal age, Filipino, single, a resident of Purok Tunggo, Minaog, Dipolog
City, Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and
state:

That I was a holder and possessor of a Form 137 or card issued by Saint Vincent’s College, Dipolog
City;

That I discovered that the original copy of my Form 137 was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said Form 137.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2024, at
Dipolog City.

DIANA MARIE S. SALIRING

(Affiant)
JRMSU School ID#DC-21-A-00896
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at Dipolog City.

Doc. No.

Page No.

Book No.

Series of 2024
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT

I:CHITO L. OPULENTISIMA, of legal age, Filipino, married, a resident of Old

Airport Road, Sicayab, Dipolog City, Zamboanga del Norte after having
been duly sworn in accordance with law, hereby depose and state:

That I am the owner of chainsaws which has a brand/model of Stihl with

Serial Number 188388811 and 188388915;

That I intend to register/renew the permit of the said chainsaws before the
Department of Environment and Natural Resources;

That one of its requirements is proof of engaging in profession or trade

using the said chainsaws;

That I am personally engaged in business/trade of cutting trees using my

said chainsaws. That this is my work/profession;

That I hereby attest that the said chainsaws will be used for legal purposes
and activities only;

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

statements.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2024, at Dipolog City.

CHITO L. OPULENTISIMA

(Affiant)

Philippine ID#5639-8170-1657-2645
With photo
SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at
Dipolog City showing her document of identification as indicated above.
Doc. No.

Page No.

Book No.

Series of 2024

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF MEMBERSHIP

I:JORGE A. JAUCULAN, of legal age, Filipino, married, a resident of Santa Fe,

Piǹan, Zamboanga del Norte after having been duly sworn in accordance
with law, hereby depose and state:

That I am the Cooperative Business Manager of STA. FE PRODUCER’S

COOPERATIVE,a duly registered cooperative with the Cooperative
Development Authority(CDA);

That I hereby attest that the said cooperative has the following
cooperators/members, namely:
1.JUANITO J. DAGPIN 14.LOURDES P. BALINGIT
2. TEODORO B. BOLO 15.DIONEBEN B. GUMAMAN
3. JORGE A. JAUCULAN 16.PAULINO R. DESCALIAR
4. FERDINAND A. BOLO 17.EGNACIO B. BOLO
5.VISITACION G. FERRAREN 18.SILVERIO C. BALASI
6.JAIME B. GORDUBE 19.NELSON GAMIAW
7.ROQUIE E. TAYASAW 20.JOSERI G. GUMAMAN
8.ALBERTA P. GUMAWON 21.JOSE P. GUMAWON
9.LEONILA D. TAMPARONG 22.JOCELYN B. BOSTILLO
10.ROSITA C. SALOMON 23.NORMA S. SUMBILON
11.BUENAVENTURADA M. ONTOLAN 24.ANITA E. PACANG
12.ERLINDA B. LUMANAO 25.PIO L. GALLEPOSO
13.NICOLAS R. COMPANIA

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

statements and for the purpose of attesting the membership of the
cooperative.

IN WITNESS WHEREOF, I have hereunto affixed my signature this 12 th day of

February 2024, at Dipolog City.

JORGE A. JAUCULAN
 (Affiant)

OSCA ID#2943-Pinan,ZN
With photo

SUBSCRIBED AND SWORN to before me this 12th day of February 2024, at

Dipolog City showing her document of identification as indicated above.
Doc. No.3860

Page No.II

Book No.LXII

Series of 2024

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I:KEN C. RECOSOSA, of legal age, Filipino, single, a resident of Sta.Filomena,

Dipolog City, Zamboanga del Norte after having been duly sworn in
accordance with law, hereby depose and state:

That I was a holder and possessor of Drivers License and its Original Copy of
Official Receipt(OR) issued by the Land Transportation Office(LTO);

That recently, I discovered that my said drivers license and its original copy
of OR was lost;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
drivers license and original copy of OR.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2024, at Dipolog City.

KEN C. RECOSOSA

(Affiant)

Valid ID#___________
 With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at

Dipolog City showing her document of identification as indicated above.

Doc. No.

Page No.

Book No.

Series of 2024

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, INOCENCIO GALISTE CAǸETE, of legal age, Filipino, widower, a resident of

Lower Turno, Dipolog CIty Zamboanga del Norte after having been duly
sworn in accordance with law, hereby depose and state:

That I was a holder and possessor of a Philhealth identification card issued

by Philippine Health Insurance Corporation(Philhealth);

That recently, I discovered that my Philhealth card was lost;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
Philhealth card.
IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of
__________ 2024, at Dipolog City.

INOCENCIO GALISTE CAǸETE

(Affiant)
AFP ID#OTAG-EP-709969-6613
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at

Dipolog City showing his/her document of identity as indicated above.

Doc. No.___

Page No.___

Book No.___

Series of 2024

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, NOVA MAPAS SOLITANA, of legal age, Filipino, single, a resident of Purok

4, Brgy. Uno, Katipunan, Zamboanga del Norte after having been duly
sworn in accordance with law, hereby depose and state:

That I was a holder and possessor of a Philippine Passport with Number

P7258224B issued by the Department of Foreign Affairs;

That on February 26 2022, I discovered that my passport was lost;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
passport.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2024, at Dipolog City.

NOVA MAPAS SOLITANA

(Affiant)
Philhealth ID#09-201859330-2
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at

Dipolog City showing his/her document of identity as indicated above.

Doc. No.___

Page No.___

Book No.___

Series of 2024

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x
 AFFIDAVIT OF LOSS

I, AVERIL IVES YU WEE SIT, of legal age, Filipino, with office address of Kasambagan, Cebu City,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I was possessor of Certificate of Registration issued by the Bureau of Internal Revenue under the
name of LIM, DANNY T. as taxpayer.

That recently, while I was trying to arrange several office documents and locating the said BIR
Certificate of Registration, but it was lost and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said Original Copy of Certificate of Registration.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2024, at
Dipolog City.

AVERIL IVES YU WEE SIT

(Affiant)
Philippine ID#4184-5719-5308-2142
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2024
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT

We: LORNA S. SOLEDAD, widow; and, DIOSDADO G. SAGARIO, married to Lorna O. Sagario; all of legal
age; all Filipinos; all residents of Manukan, Zamboanga del Norte after having been duly sworn in
accordance with law, hereby depose and state:

That we are the parties to the Deed of Absolute Sale notarized by Atty Eulogio L Lagudas,Jr per Doc.
No.6526, Page No.21, Book No.49, Series of 2021 over a portion of 400 square meters of Lot 35, Psd-
09-026513 located at Punta Blanca, Manukan, Zamboanga del Norte covered by TCT No.T-57554
containing a total area of 8,074 square meters;

That we hereby confirm that the area of 400 square meters is now denominated as Lot No.35-K and
Lot 35-L, both have total land area of 400 square meters;

We are executing this Affidavit to attest to the truth of the foregoing statements and for transfer of
title in favor of buyer from seller.

IN WITNESS WHEREOF, we have hereunto affixed our signatures this ___ day of __________ 2024, at
Dipolog City.

LORNA S. SOLEDAD
(Affiant)
 OSCA ID#MAN-17-724, Manukan, ZN
With photo

DIOSDADO G. SAGARIO
(Affiant)
VIN#7207-0064A-D1854DGS10000
With photo
Represented by:

CRISANTO S. ENOY
Per SPA notarized by Ivo Mandantes under Doc No.1028 Page No18, Book No.XXXVII, Series of 2023

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at Dipolog City.

Doc. No.__
Page No.__
Book No.__
Series of 2024

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, VIA C. APIGO, of legal age, Filipino, with office address of Estaka, Dipolog City, Zamboanga del Norte
after having been duly sworn in accordance with law, hereby depose and state:

That I am a personnel of Hotel Camila, Inc with registered address of Gen Luna St Estaka, Dipolog City.
The said business is registered at Bureau of Internal Revenue and was issued a Certificate of
Registration.

That recently, while the personnel were trying to arrange several office documents and locating the
said BIR Certificate of Registration, but it was lost and could not be found;
That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said Original Copy of Certificate of Registration.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2024, at
Dipolog City.

VIA A. APIGO
(Affiant)
TIN#747-493-233

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2024
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I:ROSELLER P. GERZON, of legal age, Filipino, married, a resident of Polanco,

Zamboanga del Norte after having been duly sworn in accordance with law,
hereby depose and state:

That I was a holder and possessor of Certificate of Registration of my vehicle

with following details: Engine No.RWI62FNKJC002035; Chassis
No.RWCLHKJOGP002035;Make:Rusi; Series:Chariot 175;Color:Red, and its
Original Copy of Official Receipt(OR) issued by the Land Transportation
Office(LTO);

That recently, I discovered that my said certificate of regisration and its

original copy of OR was lost;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
certificate of registration and original copy of OR.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2024, at Dipolog City.

ROSELLER P. GERZON

(Affiant)

Pag-ibig MID#1760-0005-4207
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at

Dipolog City showing her document of identification as indicated above.

Doc. No.

Page No.
Book No.

Series of 2024

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I:KERBIEN F. ROMERO, of legal age, Filipino, single, a resident of Dampalan,

Dapitan City, Zamboanga del Norte after having been duly sworn in
accordance with law, hereby depose and state:

That I was a holder and possessor of Drivers License and its Original Copy of
Official Receipt(OR) issued by the Land Transportation Office(LTO);

That recently, I discovered that my said drivers license and its original copy
of OR was lost;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
drivers license and original copy of OR.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2024, at Dipolog City.

KERBIEN F. ROMERO

(Affiant)

SVC School ID#2022-00180

With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at

Dipolog City showing her document of identification as indicated above.

Doc. No.

Page No.

Book No.

Series of 2024
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, EMELLY T. OGA, of legal age, Filipino,married, a resident of Lopero, Jose

Dalman, Zamboanga del Norte after having been duly sworn in accordance
with law, hereby depose and state:

That I was a holder and possessor of a Katipunan Rural Bank Passbook with
account number 002-20-1051938 and Automated Teller Machine(ATM) Card
with number 002-30-0002183 of the same bank;

That recently, I found out that my said Passbook and my said ATM card
were lost;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
Passbook and ATM card.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2024, at Dipolog City.

EMELLY T. OGA
(Affiant)
PRC ID#0490626
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at

Dipolog City.

Doc. No.___

Page No.___

Book No.___

Series of 2024
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT FOR SEEKING OF FORGIVENESS

I:RITCHEL PANCHO, of legal age, Filipino, widow of Lope Pancho, a resident

of Guinles, Polanco, Zamboanga del Norte after having been duly sworn in
accordance with law, hereby depose and state:

That I am the surviving spouse of Lope Pancho;

That my late husband died;

That after the burial of my late husband, I and the immediate relatives of
my husband including his brother Teofilo Pancho agreed that we will not
receive any cash assistance from the family of Aba;

That after the wake of my late husband, I had received a cash assistance
from Irish Aba, the “in-law” of the Abas, who had a physical altercation of
my late husband. That the money was used for the 40 th day remembrance
of my late husband;

That I am wholeheartedly asking forgiveness from Teofilo Pancho regarding

this matter and there was no intention of hurting the feelings of my
husband’s brother and his immediate family;

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

statements and for the purpose of asking forgiveness from Teofilo Pancho.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2024, at Dipolog City.

RITCHEL PANCHO

(Affiant)

Valid ID#__________________
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at

Dipolog City showing her document of identification as indicated above.

Doc. No. Book No.

Page No. Series of 2024

Book No.

Series of 2024

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I:JOVITO T. SUMAYLO, of legal age, Filipino, single/married, a resident of Jose

Rizal Katipunan, Zamboanga del Norte after having been duly sworn in
accordance with law, hereby depose and state:

That I was a holder and possessor of updated original copy Official Receipt
of registration over motor vehicle with CR No.198306812, Engine
No.34C5001794, Chassis No.34C5001907 issued by the Land Transportation
Office(LTO) ;

That recently, I discovered that my said original copy of OR, were lost;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
original copy of OR.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2024, at Dipolog City.

JOVITO T. SUMAYLO

(Affiant)

Drivers License#J01-02-039514
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at

Dipolog City showing her document of identification as indicated above.

Doc. No.

Page No.

Book No.

Series of 2024
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT

I, MARLYN T. FABILLAR, of legal age, Filipino, single/married, a resident of Dipolog City, Zamboanga
del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I was a holder of original copy of Special Power of Attorney(SPA) executed by Lucia Ceballos
Kubota in favor of Jerry R. Ceballos notarized by Ivo Mandantes under Doc. No.3884, Page No.55,
Book No.XXIX, Series of 2023;

That the original copies of the said SPA were presented before the Bureau of Internal Revenue,
Department of Agrarian Reform, Assessor’s Office and other offices and were surrendered;

That upon reaching Register of Deeds for DIpolog City for annotation of my transaction, I have
exhausted all original copies hence I have only photostatic copy of the said documents which is duly
certified true copy by the notary public;

That I tried to locate and contact the executor Lucia Ceballos Kubota however she is no longer living in
nearby area as she is currenly living in Japan so it is impossible to have her execute the SPA;

That I hereby execute this affidavit to justify the non-presentation of the original copy of
abovementioned SPA.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2024, at
Dipolog City.

MARLYN T. FABILLAR
(Affiant)
Phil. ID#3086-9416-5702-5037
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at Dipolog City.

Doc. No.

Page No.

Book No.

Series of 2024
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, REY L. PURO, of legal age, Filipino, single/married, a resident of Sicayab, Dipolog City, Zamboanga
del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I was a holder of an official receipt issued by EMCOR, Inc. in favor of John Runar Naranjo in the
amount of P10,000.00 with receipt number CG468-00017347.

That the original copy was lost;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said original copy of the receipt.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2024, at
Dipolog City.

REY L. PURO
(Affiant)
SSS #10-0684816-8
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at Dipolog City.

Doc. No.

Page No.

Book No.

Series of 2024
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I:HERARD B. MANDANTES, of legal age, Filipino, married, a resident of

Dapitan City, Zamboanga del Norte after having been duly sworn in
accordance with law, hereby depose and state:

That I was a holder and possessor of Drivers License and its Original Copy of
Official Receipt(OR) issued by the Land Transportation Office(LTO); Tax
Identification Number(TIN) card issued by Bureau of Internal Revenue;
Voter’s Identification card issued by Commission on Elections and LTO
Original Copies of Certificate of Registration my vehicle with Plate Number
090804 and its official receipt;

That recently, I discovered that my wallet containing the said Drivers

License and its Original Copy of Official Receipt(OR) issued by the Land
Transportation Office(LTO); Tax Identification Number(TIN) card issued by
Bureau of Internal Revenue; Voter’s Identification card issued by
Commission on Elections and LTO Original Copies of Certificate of
Registration my vehicle with Plate Number 090804 and its official receipt;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
Drivers License and its Original Copy of Official Receipt(OR) issued by the
Land Transportation Office(LTO); Tax Identification Number(TIN) card issued
by Bureau of Internal Revenue; Voter’s Identification card issued by
Commission on Elections and LTO Original Copies of Certificate of
Registration my vehicle with Plate Number 090804 and its official receipt.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2024, at Dipolog City.

HERARD B. MANDANTES
 (Affiant)

Valid ID#____________
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at

Dipolog City showing her document of identification as indicated above.

Doc. No.

Page No.

Book No.

Series of 2024

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, REZEL P. QUINLOG, of legal age, Filipino, a resident of Guinles, Polanco, Zamboanga del Norte after
having been duly sworn in accordance with law, hereby depose and state:

That I am a graduate at Saint Vincent’s College, Inc.-Dipolog City;

That I was holder and possessor of a Diploma as a graduate of said school;

That recently I discovered that the original copy of my Diploma was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said document.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2024, at
Dipolog City.

REZEL P. QUINLOG
(Affiant)
Driver’s License#J01-17-003836 valid until 2032/09/09
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at Dipolog City.

Doc. No.

Page No.

Book No.

Series of 2024
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, LEOPOLDO G. ALEJO, of legal age, Filipino, married, a resident of Sicayab, Dipolog City, Zamboanga
del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder of original copy of Resolution dated November 14, 2023 was issued by the
Honorable Court of RTC Branch 6, Dipolog over a petition docketed as MSP No.10796.

That the original copy was lost;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said original copy of the resolution.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2024, at
Dipolog City.

LEOPOLDO G. ALEJO
(Affiant)
Drivers License#C05-98-111132

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at Dipolog City.

Doc. No.

Page No.

Book No.

Series of 2024
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, LILY T. PORACAN, of legal age, Filipino, single/married, a resident of Estaka, Dipolog City,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of my Automated Teller Machine(ATM) card issued b y Union Bank
of the Philippines.

That on August 12, 2021, my said ATM card was lost;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said ATM card issued by Union Bank of the Philippines.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2021, at
Dipolog City.

LILY T. PORACAN
(Affiant)
OSCA ID#16457
Issued by Dipolog City

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at Dipolog City.

Doc. No.

Page No.

Book No.

Series of 2021
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I:ALFREDO D. ADRIAS, of legal age, Filipino, married, a resident of Barra,

Dipolog City, Zamboanga del Norte after having been duly sworn in
accordance with law, hereby depose and state:

That I was a holder and possessor of Drivers License and its Original Copy of
Official Receipt(OR) issued by the Land Transportation Office(LTO) and
Office of the Senior Citizen Affairs (OSCA) Identification card;

That on December 23, 2023, I discovered that my wallet containing the said
drivers license and its original copy of OR, and OSCA ID was lost;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
drivers license and original copy of OR and OSCA ID.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2024, at Dipolog City.

ALFREDO DURAN ADRIAS

(Affiant)

Valid ID#____________
With photo
SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at
Dipolog City showing her document of identification as indicated above.

Doc. No.

Page No.

Book No.

Series of 2024

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, RONNEL A. MANDANTES, of legal age, Filipino, single, a resident of Turno, Dipolog City, Zamboanga
del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I was issued a TOP by the TMO of Dipolog City.

That I happened to lost the said TOP;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said TOP.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2024, at
Dipolog City.

RONNEL A. MANDANTES
(Affiant)
UMID ID#CRN-0111-5572104-2

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at Dipolog City.

Doc. No.

Page No.

Book No.

Series of 2024
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ELLAH JANE E. YU, of legal age, Filipino, single, a resident of Sta. Isabel, Dipolog City, Zamboanga del
Norte after having been duly sworn in accordance with law, hereby depose and state:

That I was a student of Sain Vincent’s College, Dipolog City.

That I was issued a copy of my Honorable Dismissal ;

That recently I found out that my Honorable Dismissal was lost.

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said Honorable Dismissal and thereafter requesting
replacement thereon.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2024, at
Dipolog City.

ELLAH JANE E. YU
(Affiant)
 Philippine ID#2731-5469-1489-5835
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at Dipolog City showing
their/his/her document of identity.

Doc. No.__
Page No.__
Book No.__
Series of 2024

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT

I, SUSAN DUTERTE-BERGAS, of legal age, Filipino, widow, a resident of Poblacion South,

Polanco, Zamboanga del Norte after having been duly sworn in accordance with law, hereby
depose and state:

That I am registered owner of parcel of land known as Lot 3244-H, CSD-09-001904 located at
Polanco, Zamboanga del Norte covered by Original Certificate of Title No.P-31702 containing
an area of 1,058 square meters;

That we sold a portion of 558 square meters to Mr. Francisco Laurque, married to Virgilia
Cajocon;

That the remaining portion was then 500 square meters;

That there are four(4) tax declarations(TD) over the said one property, to wit: TD No.14-0002-
01262 for an area of 250 square meters, TD No.14-0002-01263 for an area of 181 square
meters, TD No.14-0002-01264 for an area of 196 square meters, and TD No.14-0002-01265 for
an area of 431 square meters;
That of all four TDs, TD No.14-0002-01265 is registered in the name of Francisco Laurque with
an area of 431 square meters, thus, Francisco Laurque has a remaining of 127 square meters
which belong to TD No.14-0002-01263. That thus, TD No.14-0002-01263 has a remaining area
of 54 square meters, under the name of Susan Duterte and all other TDs with numbers 14-
0002-01262 and 14-0002-01263 are also under my name;

That thus, my remaining area of 500 square meters is covered by Tax Declaration Numbers 14-
0002-01262 and 14-0002-01263, and partly TD No.14-0002-01263 for an area of 54 square
meters;

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

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2024,
at Dipolog City.

SUSAN DUTERTE-BERGAS

(Affiant)

PhilPost ID#PRNM83180040792P

With photo

SUBSCRIBED AND SWORN to before me showing his/her document of identification as shown

above this ___ day of _________ 2024, at Dipolog City.

Doc. No

Page No

Book No

Series of 2024

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, MAICHEL M. BANSGON, of legal age, Filipino, single, a resident of Galas, Dipolog City,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose
and state:

That I was a possessor and holder of a Pantawid Pamilyang Pilipino Program(4Ps) cash card of
Department of Social Welfare and Development(DSWD) issued by Land Bank of the
Philippines.

That recently my said cash card was lost;

That despite effort to recover the same but it was naught.

Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements
and for the purpose of attesting to the loss of the said 4Ps cash card.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2024,
at Dipolog City.

MAICHEL M. BANSAGON

(Affiant)

DSWD 4Ps ID#097210001-9998-46047

With photo

SUBSCRIBED AND SWORN to before me showing his/her document of identification as shown

above this ___ day of _________ 2024, at Dipolog City.

Doc. No

Page No

Book No

Series of 2024

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, MAUREEN AVA I. LIHAY-LIHAY, Filipino, of legal age, married, and a

resident of Minaog, Dipolog City, Zamboanga del Norte after having been
duly sworn in accordance with law, hereby depose and state:

That I was a holder and possessor of an Automated Teller Machine(ATM)

card with account number 0526-3168-86 which my payroll ATM card as
DPWH employee issued by Landbank of the Philippines ;

That recently, my said ATM card was lost;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
ATM card.
IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of
__________ 2024, at Dipolog City.

MAUREEN AVA I. LIHAY-LIHAY

(Affiant)

VIN#7202-0133A-I2674ML20000

With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at

Dipolog City.

Doc. No.____
Page No.____
Book No.____
Series of 2024

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT

I, ARLINOVE M. MONTEALTO, Filipino, of legal age, married, and with office

address of 1st Valley Bank, Inc., Gen Luna St., Dipolog City, Zamboanga del
Norte after having been duly sworn in accordance with law, hereby depose
and state:

That I am the Branch Manager of 1st Valley Bank, Inc.-Dipolog City Branch;

That I hereby certify and attest that the abovementioned bank is legally
qualified and allowed to acquire private lands in the Philippines

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

statements.
IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of
__________ 2024, at Dipolog City.

ARLINOVE M. MONTEALTO
(Affiant)
Valid ID#___________
With phot

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at

Dipolog City.

Doc. No.__
Page No.__
Book No.__
Series of 2024

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, IVER E. SESTOSO, Filipino, of legal age, single, and a resident of North

Proper, Galas, Dipolog City, Zamboanga del Norte after having been duly
sworn in accordance with law, hereby depose and state:

That I was a holder and possessor of a collection receipt with number 819R-
LCR00059064 under the name of Transcycle Dipolog;

That recently, my said receipts with color of yellow and green copies was
lost;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.
As such, I am executing this Affidavit of Loss to attest to the truth of the
foregoing statements and for the purpose of attesting to the loss of the said
receipts.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2024, at Dipolog City.

IVER E. SESTOSO
(Affiant)
Philippine ID#3073-1964-1602-7485
With phot

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at

Dipolog City.

Doc. No.9844
Page No.96
Book No.LXV
Series of 2024
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, SHARIKA D. JUMAWAN, Filipino, of legal age, single/married, and a resident

of Blk13, Lot 18 VCH, Obay, Polanco, Zamboanga del Norte after having
been duly sworn in accordance with law, hereby depose and state:

That I was a holder and possessor of receipts issued by Cebuana Lhuillier-

CityMall 61820 Dipolog City Branch for pawned jewelries namely Neck Cont
PDT, Pulcera, Earring with Pawnticket No.61820NP003369, 61820NP003436
& 61820NP003437, respectively, in the amount of P11,622.00; P21,800.00;
and, P5,750.00, respectively, all dated October 31, 2023 and November 12,
2023, respectively;

That recently, my said receipts were lost;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
receipts.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2024, at Dipolog City.

SHARIKA D. JUMAWAN
(Affiant)
Drivers License#J01-07-001696
With phot

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at

Dipolog City.

Doc. No.__
Page No.__
Book No.__
Series of 2024
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, JUDELYN R. ENTERO, of legal age, Filipino, married, and with address of Polo,
Dapitan City, Zamboanga del Norte after having been duly sworn in accordance
with law, hereby depose and state:

That I was a holder and possessor of original copy of e-Certificate Authorizing

Registration(eCAR) for the estate tax of late Miguel Caysido issued by the Bureau
of Internal Revenue-RDO 91;

That recently I discovered that my said documents were lost;

That despite effort to recover the same but it was naught. Hence, I considered it
as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
statements and for the purpose of attesting to the loss of the said documents.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2024, at Dipolog City. massive

JUDELYN R. ENTERO
(Affiant)
Voters ID#72010131AJ2568JRE20001-5
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at Dipolog
City showing his/her document of identity as indicated above.

Doc. No.___

Page No.___

Book No.___

Series of 2024
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I:MA. THERESA S. ENERO, of legal age, Filipino, single/married, a resident of

Dipolog City, Zamboanga del Norte after having been duly sworn in
accordance with law, hereby depose and state:

That I am representative of Maria Khristine Enoy Bastasa, owner of Maria

Khristine Store located at Ranillo St., Dipolog City;

That she was issued with Official Receipt with Nos. 4750 until 5000 with
Authority to Print issued by BIR;

That the said receipts were lost;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
original copy of ORs.
IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of
__________ 2024, at Dipolog City.

MA. THERESA S. ENERO

(Affiant)

Valid ID#______________
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at

Dipolog City showing her document of identification as indicated above.

Doc. No.

Page No.

Book No.

Series of 2024

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, JOHANNA FATIMA LOU G. BAHI-AN, of legal age, Filipino, single, a resident of Tolon, Rizal,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I was a holder and possessor of a School Identification(ID) Card issued by my school Colegio de
San Francisco Javier, located at Rizal, Zamboanga del Nrote for being its student.

That recently, while I was trying to look for my said school ID, then I found out that my school ID was
lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said School ID.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of ______ 2024, at Dipolog
City.
 JOHANNA FATIMA LOU G. BAHI-AN
(Affiant)
Valid ID#___________
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at Dipolog City.

Doc. No.
Page No.
Book No.
Series of 2024

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, TEODORVINE S. EVARDO, of legal age, Filipino,widow resident of Central Barangaay, Dipolog City,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am the holder and possessor of papers on the payments of donor’s taxes and other BIR related documents
of ELPIDIO M. SAGARIO and other which were issued by BIR;

That I have lost the said receipts/certificate;

That despite effort to recover the same but it was naught.

That I/he considered it as totally lost.

That I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for the purpose
of attesting to the loss of the said BIR receipts/certificates.

IN WITNESS WHEREOF, I have hereunto affixed my signature this __th day of _______ 2024, at Dipolog
City.

TEODORVINE S. EVARDO
(Affiant)

Valid ID#__________

SUBSCRIBED AND SWORN to before me this ___th day of ________ 2024, at Dipolog City.

DOC.NO. ______

PAGE NO.___

BOOK NO.___

SERIES OF 2024

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I:ALFREDO C. TIMONIO,JR, of legal age, Filipino, single/married, a resident of

Turno, Dipolog City, Zamboanga del Norte after having been duly sworn in
accordance with law, hereby depose and state:

That I was a holder and possessor of updated original copy Official Receipt
of registration over motor vehicle with CR No.281411852, Engine
No.E3W7E0025506, Chassis No.PAORE3210H0025971 issued by the Land
Transportation Office(LTO) ;

That recently, I discovered that my said original copy of OR, were lost;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.
As such, I am executing this Affidavit of Loss to attest to the truth of the
foregoing statements and for the purpose of attesting to the loss of the said
original copy of OR.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2024, at Dipolog City.

ALFREDO C. TIMONIO,JR

(Affiant)

UMID ID#CRN-0111-1369605-4
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at

Dipolog City showing her document of identification as indicated above.

Doc. No.

Page No.

Book No.

Series of 2024

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, CARLO Q. RAZO, of legal age, Filipino,single, a resident of Lapu-lapu St.,

Estaka, Dipolog City, Zamboanga del Norte after having been duly sworn in
accordance with law, hereby depose and state:

That I was a holder and possessor of a check issued by Visaya Amusement

Corp under Account No.007-24-80386-8 at Metrobank- Gaisano Tabunok,
Talisay City Branch in the amount of 3,069.44;
That recently, I found out that my check was lost;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
check.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2024, at Dipolog City.

CARLO Q. RAZO
(Affiant)
TIN#344-873-668
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at

Dipolog City.

Doc. No.___

Page No.___

Book No.___

Series of 2024

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT

I, ROSEMARIE J. PERATER, of legal age, Filipino, married, a resident of Sta.

Filomena, Dipolog City, Zamboanga del Norte after having been duly sworn
in accordance with law, hereby depose and state:

That I am proprietor of KMP Construction;

That I was issued Official Receipts with BIR Authority to Print valid until July
13, 2022;

That however there was a mistake because I unknowingly issued Official

Receipt No.0041 on October 5, 2023 to PPA-Dapitan City in the amount of
P936,826.51 and Official Receipt No.0044 on October 20,2023 to PPA-
Dapitan City in the amount of P936,073.56, which were issued beyond the
validity date;

That due to this mistake, I paid penalty to the BIR in the amount of
P10,000.00(per attached BIR Form No.0605);

That I execute this affidavit to justify the issuance of official receipts beyond
its validity.

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

statements.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2024, at Dipolog City.

ROSEMARIE J. PERATER
(Affiant)
OSCA ID#23239-Dipolog City
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at

Dipolog City.

Doc. No.___

Page No.___

Book No.___

Series of 2024

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x
 AFFIDAVIT OF ACKNOWLEDGMENT

I, ROELITA TEOLOGO GREGORIO, of legal age, Filipino, widow, a resident of

Layawan, Sinonoc, Dapitan City, Zamboanga del Norte after having been
duly sworn in accordance with law, hereby depose and state:

That I was the nanny/carer of late LILIA SALES ROSAL;

That I was engaged only to take care the above said person since May 2012
until she died on November 2023;

That during my employment I was paid monthly at P4,000.00 Philippine

currency from May 2012 until January 2018, and in February 2018 until
November 2023, I was paid monthly P5,000.00 Philippine currency;

That all of my wages/salaries was paid by ROSMELITA SALES ROSAL only;

As such, I am executing this Affidavit of Acknowledgment to attest to the

truth of the foregoing statements and for the purpose of attesting to the
acknowledgment of sum of money stated above.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2024, at Dipolog City.

ROELITA TEOLOGO GREGORIO

(Affiant)
SSS ID#06-1045496-5
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at

Dipolog City.

Doc. No.___

Page No.___

Book No.___

Series of 2024
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, CHARLENE CARREON TUMARONG-BARRO, of legal age, Filipino,married, a

resident of Sangkol, Dipolog City, Zamboanga del Norte after having been
duly sworn in accordance with law, hereby depose and state:

That I was a holder and possessor of a Lorenzo Tan Multipurpose

Cooperative(LTMPC)-Dapitan City Branch Passbook;

That recently, I found out that my LTMPC Passbook was lost;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
Passbook.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2024, at Dipolog City.

CHARLENE CARREON TUMARONG-BARRO

(Affiant)
Phil Passport No.P4815573B
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at

Dipolog City.

Doc. No.___

Page No.___

Book No.___

Series of 2024
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ANNA RHEA MICHELLE S. BUREROS, of legal age, Filipino, single, a resident of Linabo, Dapitan City,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am the daughter of NARCISA SALDON BUREROS, who died on December 15, 2023;

That before she died, she informed me that she was a member of Paglaum Multi-purpose
Cooperative- Dipolog City Branch, with address of Dipolog City; That she has passbooks in the said
cooperative;

That after she died I was looking for the passbooks with account numbers 11-02194-9 for CBU and 00-
01850-7 for savings of the said cooperative, but it was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said passbooks.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2024, at
Dipolog City.

ANNA RHEA MICHELLE S. BUREROS

(Affiant)
Valid ID#____________

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2024
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, AXL ANNE C. BAEL, of legal age, Filipino, single, a resident of Sicayab, Dipolog City after having been
duly sworn in accordance with law, hereby depose and state:

That I was a holder and possessor of a School Identification(ID) Card issued by my school Dipolog
Medical Center College Foundation, Inc., Dipolog City for being its student.

That recently, while I was trying to look for my said school ID, then I found out that my school ID was
lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said School ID.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of ______ 2024, at Dipolog
City.

AXL ANNE C. BAEL

(Affiant)
 Drivers License#J01-19-009175
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at Dipolog City.

Doc. No.
Page No.
Book No.
Series of 2024
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, MANUEL L. TABIGNE, of legal age, Filipino, married to Mariasol M. Tabigne, a resident of Gulayon,
Dipolog City, Zamboanga del Norte after having been duly sworn in accordance with law, hereby
depose and state:

That I was holder and possessor of my franchise sticker for my tricycle with MTOP DPLG NO.2024-
1076 issued by the Local Government of Dipolog City registered in my spouse’s name Mariasol M.
Tabigne;

That on November 12, 2023, my said vehicle was involved in a vehicular accident wherein my
windshield was shattered to pieces. I discovered that the sticker of tricycle which was attached in the
shattered windshield was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said sticker.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2024, at
Dipolog City.

MANUEL L. TABIGNE
(Affiant)
Driver’s License#N03-93-146818
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at Dipolog City.

Doc. No.

Page No.

Book No.

Series of 2024
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I:MICHELLE C. SALAZAR, of legal age, Filipino, single/married, a resident of

Turno, Dipolog City, Zamboanga del Norte after having been duly sworn in
accordance with law, hereby depose and state:

That I was a holder and possessor of Certificate of Registration over motor

vehicle with CR No.38978296-0, Engine No.K6A-6488587, Chassis
No.DA63T-339921 and its Original Copy of Official Receipt(OR) issued by the
Land Transportation Office(LTO) ;

That recently, I discovered that my said CR and its original copy of OR, were
lost;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
CR and original copy of OR.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2024, at Dipolog City.

MICHELLE C. SALAZAR

(Affiant)

Phil. ID#6529-6179-1395-0825
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at

Dipolog City showing her document of identification as indicated above.

Doc. No.

Page No.

Book No.

Series of 2024
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I:DOMINIC MAIKO S. DIAZ, of legal age, Filipino, single, a resident of Turno,

Dipolog City, Zamboanga del Norte after having been duly sworn in
accordance with law, hereby depose and state:

That I was a holder and possessor of UMID card which is also an ATM card
with account number 5167505572 issued by LandBank of the Philippines-
Dipolog City Branch ;

That recently, I discovered that the said card was lost;

That despite effort to recover the same but it was naught. Hence, we
considered it as totally lost.

As such, we are executing this Affidavit of Loss to attest to the truth of the
foregoing statements and for the purpose of attesting to the loss of the said
card.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2024, at Dipolog City.

DOMINIC MAIKO S. DIAZ

(Affiant)
UMID ID#CRN-021-1746-9913-9
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at

Dipolog City showing his/her document of identity as indicated above.

Doc. No.

Page No.

Book No.

Series of 2024
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I:JAMES RALPH V. ALETA, of legal age, Filipino, single, a resident of Olingan,

Dipolog City, Zamboanga del Norte after having been duly sworn in
accordance with law, hereby depose and state:

That I was a holder and possessor of ATM card with account number
5177917852 issued by LandBank of the Philippines-Dipolog City Branch ;

That recently, I discovered that the said ATM card was lost;

That despite effort to recover the same but it was naught. Hence, we
considered it as totally lost.

As such, we are executing this Affidavit of Loss to attest to the truth of the
foregoing statements and for the purpose of attesting to the loss of the said
ATM card.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2024, at Dipolog City.

JAMES RALPH V. ALETA

(Affiant)
PRC ID#1316807
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at

Dipolog City showing his/her document of identity as indicated above.

Doc. No.

Page No.

Book No.

Series of 2024

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x
 AFFIDAVIT OF LOSS

I, SANDRO CUEVAS SECOYA, JR, Filipino, of legal age, single , and a resident
of Tambak, Potol, Dapitan City, Zamboanga del Norte after having been
duly sworn in accordance with law, hereby depose and state:

That I was a holder and possessor of a Maritime Industry Authority(MARINA)

Identification card issued by MARINA;

That recently, I found out that my identification card was lost, I tried to
locate the card but it was really lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
MARINA Identification card.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2024, at Dipolog City.

SANDRO CUEVAS SECOYA,JR

(Affiant)
Seafarer’s Record Book No.A0049016
With phot

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at

Dipolog City.

Doc. No.__
Page No.__
Book No.__
Series of 2024

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x
 AFFIDAVIT OF LOSS

I, ROCELL P. GAMOLO, Filipino, of legal age, married , and a resident of

Estaka, Dipolog City, Zamboanga del Norte after having been duly sworn in
accordance with law, hereby depose and state:

That I was a holder and possessor of receipt with number 132103553-2023-

00500 dated 18 August 2023 issued by MLhuillier for pawned jewelry
describd as YG Ring DEF in the amount of P6,400.00;

That recently, I found out that my receipt was lost, I tried to locate the
receipts but it was really lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
receipt.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2024, at Dipolog City.

ROCELL P. GAMOLO
(Affiant)
Drivers License#J01-20-009336
With phot

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at

Dipolog City.

Doc. No.__
Page No.__
Book No.__
Series of 2024
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I:ROLANDO P. GERZON, of legal age, Filipino, married, and with office address of
Lingasad Elementary School, Lingasad, Polanco, Zamboanga del Norte, after
having been duly sworn in accordance with law, hereby depose and state:

That I am the School Principal of Lingasad Elementary School;

That I am accountable officer of properties owned by the agency;

That sometime December 18, 2023 at around 10:06 in the morning, a fire incident
razed three-classroom Bagong Lipunan Building of said school;

That the following properties were inside the rooms during the said fire incident, to wit:

Ite DESCRIPTION QUANTI UNIT TOTAL REMARKS

m TY PRICE PRICE
No. (Php) (Php)

1 Television Set 3 sets 10,000. 30,000.0 Installed at

00 0 the rooms

2 Electric Fan 3 units 5,000.0 15,000.0 Installed at

0 0 the rooms

3 Ceiling Fan 6 units 4,500.0 13,500.0 Installed at

0 0 the rooms

4 Wall Fan 2 units 4,000.0 8,000.00 Installed at

0 the rooms

5 Pupil’s Table 12 3,500.0 42,000.0 Used by

pieces 0 0 pupils

6 Teacher’s Table 3 3,000.0 9,000.00 Used by

0 teachers
pieces

7 Aparador 3 units 5,000.0 15,000.0 Used by

0 0 teachers/pupi
ls

8 Plastic Chairs 60 500.00 30,000.0 Used by

pieces 0 teachers/pupi
ls
9 Chalkboard 9 2,000.0 18,000.0 Used by
pieces 0 0 teachers/pupi
ls

10 Refrigerator(Small) 1 unit 6,000.0 6,000.00 Used by

0 teachers/pupi
ls

11 Water Dispenser 1 unit 6,000.0 6,000.00 Used by

0 teachers/pupi
ls

12 Printer(3 in 1) 2 units 12,500. 25,000.0 Used by

00 0 teachers

13 Rice Cooker 1 unit 800.00 800.00 Used by

teachers

14 Blender 1 unit 2,000.0 2,000.00 Used by

0 teachers/pupi
ls

15 Gas Burner 1 unit 4,500.0 4,500.00 Used by

0 teachers/pupi
ls

16 Frying Pan 1 piece 950.00 950.00 Used by

teachers/pupi
ls

17 Kettle(Big) 1 piece 850.00 850.00 Used by

teachers/pupi
ls

18 Cooking Pot 1 piece 750.00 750.00 Used by

teachers/pupi
ls

19 Drinking Glass 3 dozen 600.00 1,800.00 Used by

teachers/pupi
ls

20 Porcelain Plate 3 dozen 750.00 2,250.00 Used by

teachers/pupi
ls

21 Spoon & Fork 3 dozen 250.00 750.00 Used by

teachers/pupi
ls

22 Kitchen Knife 5 300.00 1,500.00 Used by

pieces teachers

23 Sports Equipment 5,000.00 Used by

teachers/pupi
 ls

24 Educational Toys 1 set 5,500.0 5,500.00 Used by

0 teachers/pupi
ls

25 Cabinet 5 units 4,500.0 22,500.0 Used by

0 0 teachers/pupi
ls

26 A4 bondpapers 5 boxes 1,000.0 5,000.00 Used by

0 teachers/pupi
ls

TOTAL 271,650.
00

That despite effort to recover the same but it was naught. Hence, I considered it
as totally lost;

That as such, I am executing this Affidavit of Loss to attest to the truth of the
foregoing statements and for the purpose of attesting to the loss of the said
properties/inventories.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

December 2023, at Dipolog City.

ROLANDO P. GERZON
(Affiant)

SUBSCRIBED AND SWORN to before me this ___ day of December 2023, at Dipolog City showing their documents of
identification:
Name Valid ID & Number Issuing Office
Rolando P. Gerzon J01-05-003792 LTO

DOC.NO.

PAGE NO.

BOOK NO.

SERIES OF 2023
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I:KLINT D. MONDIJAR, of legal age, Filipino, single, a resident of Turno,

Dipolog City, Zamboanga del Norte after having been duly sworn in
accordance with law, hereby depose and state:

That I was a holder and possessor of Drivers License and its Original Copy of
Official Receipt(OR) issued by the Land Transportation Office(LTO) and
Unified Multipurpose Identification(UMID) Card;

That recently, I discovered that my said drivers license and its original copy
of OR, and UMID were lost;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.
As such, I am executing this Affidavit of Loss to attest to the truth of the
foregoing statements and for the purpose of attesting to the loss of the said
drivers license and original copy of OR and UMID.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2023, at Dipolog City.

KLINT D. MONDIJAR

(Affiant)

Valid ID#____________
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at

Dipolog City showing her document of identification as indicated above.

Doc. No.

Page No.

Book No.

Series of 2023

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I:JOSEPHINE A. TAMBULA, of legal age, Filipino, married, a resident of

Marapong, Sergio Osmena, Zamboanga del Norte after having been duly
sworn in accordance with law, hereby depose and state:

That I was a holder and possessor of ATM card to be used as cash card for
my 4Ps benefits issued by LandBank of the Philippines-Dipolog City Branch ;

That recently, I discovered that the said ATM card was lost;
That despite effort to recover the same but it was naught. Hence, we
considered it as totally lost.

As such, we are executing this Affidavit of Loss to attest to the truth of the
foregoing statements and for the purpose of attesting to the loss of the said
ATM card.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 202__, at Dipolog City.

JOSEPHINE A. TAMBULA
(Affiant)
DSWD 4Ps ID#097214015-0091-00084
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 202_, at

Dipolog City showing his/her document of identity as indicated above.

Doc. No.

Page No.

Book No.

Series of 202_

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I:MARLON M. ABANG, of legal age, Filipino, married, a resident of Olingan,

Dipolog City, Zamboanga del Norte after having been duly sworn in
accordance with law, hereby depose and state:

That I was a holder and possessor of ATM card to be used as cash card for
my 4Ps benefits issued by LandBank of the Philippines-Dipolog City Branch ;

That on December 26, 2023, I discovered that the said ATM card was lost;
That despite effort to recover the same but it was naught. Hence, we
considered it as totally lost.

As such, we are executing this Affidavit of Loss to attest to the truth of the
foregoing statements and for the purpose of attesting to the loss of the said
ATM card.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 202__, at Dipolog City.

MARLON M. ABANG
(Affiant)
DSWD 4Ps ID#097202008-2-11637984
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 202_, at

Dipolog City showing his/her document of identity as indicated above.

Doc. No.

Page No.

Book No.

Series of 202_

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, FERLISA R. EGUIA, of legal age, Filipino, married, a resident of Dipane, Manukan,

Zamboanga del Norte after having been duly sworn in accordance with law,
hereby depose and state:

That I was holder and possessor of a LBP Check with Number 0002675947 dated
April 27, 2023 under account name Manukan East Central School in the amount of
P1,500.00.

That I discovered that my said check was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it
as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
statements and for the purpose of attesting to the loss of the said check.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

December 2023, at Dipolog City.
 FERLISA R. EGUIA
(Affiant)
DepEd ID#4912899
With photo

SUBSCRIBED AND SWORN to before me this ___ day of December 2023, at Dipolog
City.

DOC.NO.

PAGE NO.

BOOK NO.

SERIES OF 2023

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, CENONA M. BUBURAN, of legal age, Filipino, widow, a resident of Estaka,

Dipolog City, Zamboanga del Norte after having been duly sworn in accordance
with law, hereby depose and state:

That I was holder and possessor of OSCA Identification(ID) card issued by Office of
Senior Citizen’s Affairs(OSCA).

That recently, I discovered that my said OSCA ID card was lost, and could not be
found;

That despite effort to recover the same but it was naught. Hence, I considered it
as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
statements and for the purpose of attesting to the loss of the said OSCA ID card.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

December 2023, at Dipolog City.
 CENONA M. BUBURAN
(Affiant)
GSIS Ret ID#DW-1880
With photo

SUBSCRIBED AND SWORN to before me this ___ day of December 2023, at Dipolog
City.

DOC.NO.

PAGE NO.

BOOK NO.

SERIES OF 2023

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I:EDWARD R. BENERADO, of legal age, Filipino, married, a resident of Obay,

Polanco, Zamboanga del Norte after having been duly sworn in accordance
with law, hereby depose and state:

That I was a holder and possessor of Original Copy of Certificate of

Registration(CR) with Number 12425033-5, with Plate Number JDZ360 and
Official receipt issued by the Land Transportation Office(LTO) registered in
the name of Letecia Benerado, my mother;

That recenlty, I discovered that the original copies of CR and OR were lost;
That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
original copy of CR and OR.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2023, at Dipolog City.

EDWARD R. BENERADO

(Affiant)
Drivers License#J01-08-003824
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at

Dipolog City showing her document of identification as indicated above.

Doc. No.

Page No.

Book No.

Series of 2023
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, BEA KASANDRA FACTURAN PANIGSING, of legal age, Filipino, married, a resident of Dampalan,
Dapitan City, Zamboanga del Norte after having been duly sworn in accordance with law, hereby
depose and state:

That I was a student of Jose Rizal Memorial State University, Katipunan Campus.

That I was issued a copy of my Honorable Dismissal under my maiden name BEA KASANDRA
FACTURAN.

That recently I found out that my Honorable Dismissal was lost.

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said Honorable Dismissal and thereafter requesting
replacement thereon.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2023, at
Dipolog City.

BEA KASANDRA FACTURAN PANIGSING

(Affiant)
PhilPost ID#PRNM83220466354P
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2023
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, CHONA CHUA SY, of legal age, Filipino, married, a resident of Salvador, Gutalac, Zamboanga del
Norte after having been duly sworn in accordance with law, hereby depose and state:

That I was a holder and possessor of an Official Receipt with Number 0016772 dated September 19,
2023 issued by Prov’l Government of Zamboanga del Norte for the Transfer Tax Payment in the
amount of P2,720.90.

That recently, I discovered that the receipt was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said transfer tax receipt.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2023, at
Dipolog City.

CHONA CHUA SY
(Affiant)
VIN#7223-0039A-I2259CCS20000
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at Dipolog City showing
his/her document of identity indicated above.
Doc. No.__
Page No.__
Book No.__
Series of 2023
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, JUNREYLU L. REYES, of legal age, Filipino, married, a resident of Sta.Filomena,Dipolog City,

Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I was a holder and possessor of an Automated Teller Machine(ATM) card issued by Land Bank of
the Philippines (LBP) Dapitan City Branch with Account Number 3806006164 which is my payroll ATM
card as employee of DPWH.

That recently, I discovered that the LBP ATM card was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said LBP ATM card and thereafter requesting replacement
thereon.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2023, at
Dipolog City.

JUNREYLU L. REYES
(Affiant)
TIN#269-831-341
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at Dipolog City showing
his/her document of identity indicated above.
Doc. No.__
Page No.__
Book No.__
Series of 2023
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, JOHN PAOLO R. CORRALES, of legal age, Filipino, single, a resident of Burgos, Dapitan City,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I was a holder and possessor of an Automated Teller Machine(ATM) card issued by Land Bank of
the Philippines (LBP) Dapitan City Branch which is my payroll ATM card as employee of Provincial
Government of Zamboanga del Norte.

That recently, I discovered that the LBP ATM card was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said LBP ATM card and thereafter requesting replacement
thereon.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2023, at
Dipolog City.

JOHN PAOLO R. CORRALES

(Affiant)
Drivers License#J01-15-001992
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at Dipolog City showing
his/her document of identity indicated above.
Doc. No.__
Page No.__
Book No.__
Series of 2023
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I:JOEL E. DIAMANTE, of legal age, Filipino, married, a resident of Obay,

Polanco, Zamboanga del Norte after having been duly sworn in accordance
with law, hereby depose and state:

That I was a holder and possessor of Original Copy of Certificate of

Registration(CR) for a motor vehicle with Engine No. KYT00E021026,
Chassis No. KYT00021056, Plate No.JA84181 issued by the Land
Transportation Office(LTO) registered in the name of Dulcita Diamante, my
wife;

That recenlty, I discovered that the original copies of CR and OR were lost;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
original copy of CR and OR.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2023, at Dipolog City.

JOEL E. DIAMANTE

(Affiant)
Drivers License#J01-18-004612
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at

Dipolog City showing her document of identification as indicated above.

Doc. No.

Page No.

Book No.

Series of 2023
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I:RENEHEART O. GUANTERO, of legal age, Filipino, married, a resident of

Sto.Tomas, Mutia, Zamboanga del Norte after having been duly sworn in
accordance with law, hereby depose and state:

That I was a holder and possessor of Drivers License and its Original Copy of
Official Receipt(OR) issued by the Land Transportation Office(LTO) and
Unified Multipurpose Identification(UMID) Card;

That today, I discovered that my said drivers license and its original copy of
OR, and UMID were lost;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
drivers license and original copy of OR and UMID.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2023, at Dipolog City.

RENEHEART O. GUANTERO

(Affiant)

TIN#272-158-406
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at

Dipolog City showing her document of identification as indicated above.

Doc. No.

Page No.

Book No.

Series of 2023
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, REYNALDO OGA SARANGAYA of legal age, Filipino, married, a resident of Purok Parpagayo,
Minaog, Dipolog City, Zamboanga del Norte after having been duly sworn in accordance with
law, hereby depose and state:

That I was a possessor and holder of a Pantawid Pamilyang Pilipino Program(4Ps) cash card of
Department of Social Welfare and Development(DSWD) issued by Land Bank of the Philippines
and 4Ps ID card.

That recently my said cash card and 4Ps ID card were lost;

That despite effort to recover the same but it was naught.

Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements
and for the purpose of attesting to the loss of the said 4Ps cash card and 4Ps ID card.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2023,
at Dipolog City.

REYNALDO OGA SARANGAYA

(Affiant)

VIN#72020128AB2574ROS10000-8

With photo

SUBSCRIBED AND SWORN to before me showing his/her document of identification as shown

above this ___ day of _________ 2023, at Dipolog City.

Doc. No

Page No

Book No

Series of 2023
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I:JUNREYLU L. REYES, of legal age, Filipino, married, a resident of Purok

Evergreen, Sta.Filomena, Dipolog City, Zamboanga del Norte after having
been duly sworn in accordance with law, hereby depose and state:

That I was a holder and possessor of ATM card with Account Number
3806006164 issued by LandBank of the Philippines-Dapitan City Branch ;

That recently, I discovered that the said ATM card was lost;

That despite effort to recover the same but it was naught. Hence, we
considered it as totally lost.

As such, we are executing this Affidavit of Loss to attest to the truth of the
foregoing statements and for the purpose of attesting to the loss of the said
ATM card.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2023, at Dipolog City.

JUNREYLU L. REYES
(Affiant)
Phil. ID#8532-4601-8628-9617
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at

Dipolog City showing his/her document of identity as indicated above.

Doc. No.

Page No.

Book No.

Series of 2023
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ALFEL M. ADRIAS, of legal age, Filipino, single, a resident of Barra, Dipolog City, Zamboanga del
Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a graduate of Dipolog Medical Center College Foundation, Inc.

That I was issued a copy of my Honorable Dismissal .

That recently I found out that my Honorable Dismissal was lost.

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said Honorable Dismissal and thereafter requesting
replacement thereon.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2023, at
Dipolog City.

ALFEL M. ADRIAS
(Affiant)
Passport No.P2486612C
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2023
 OMNIBUS CERTIFICATION AND VERACITY OF ALL DOCUMENTS SUBMITTED

I, LYN A. CARPIO, of legal age, Filipino, married, a resident of Central Barangay,

Dipolog City, Zamboanga del Norte after having been duly sworn in accordance
with law, do hereby depose and state:

That:

1. Each of all documents submitted in satisfaction of requirements for BEST

ELEMENTARY SCHOOL(Big School Category) position based on the Reform
Action in Basic Education Sector Reform Agenda(BESRA) in authentic copy of
original. Complete and all statements and information provide therein true
and correct;

2. I am authorizing the school selection committee or its duly authorized

representative to verify all the documents submitted;

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

November 2023, at Dipolog City.

LYN A. CARPIO
(Affiant)
Valid ID#______________
With photo

SUBSCRIBED AND SWORN to before me this ___ day of November 2023, at Dipolog
City.

DOC.NO.

PAGE NO.

BOOK NO.

SERIES OF 2023
 OMNIBUS CERTIFICATION AND VERACITY OF ALL DOCUMENTS SUBMITTED

I, LYN A. CARPIO, of legal age, Filipino, married, a resident of Central Barangay,

Dipolog City, Zamboanga del Norte after having been duly sworn in accordance
with law, do hereby depose and state:

That:

3. Each of all documents submitted in satisfaction of requirements for BEST

ELEMENTARY SCHOOL(Big School Category) position based on the Reform
Action in Basic Education Sector Reform Agenda(BESRA) in authentic copy of
original. Complete and all statements and information provide therein true
and correct;

4. I am authorizing the school selection committee or its duly authorized

representative to verify all the documents submitted;

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

November 2023, at Dipolog City.

LYN A. CARPIO
(Affiant)
Valid ID#______________
With photo

SUBSCRIBED AND SWORN to before me this ___ day of November 2023, at Dipolog
City.

DOC.NO.

PAGE NO.

BOOK NO.

SERIES OF 2023
 OMNIBUS CERTIFICATION AND VERACITY OF ALL DOCUMENTS SUBMITTED

I, JOSELITO S. TIZON, of legal age, Filipino, married, a resident of Punta, Dipolog

City, Zamboanga del Norte after having been duly sworn in accordance with law,
do hereby depose and state:

That:

5. Each of all documents submitted in satisfaction of requirements for BEST

SECONDARY SCHOOL(Big School Category)position based on the Reform
Action in Basic Education Sector Reform Agenda(BESRA) in authentic copy of
original. Complete and all statements and information provide therein true
and correct;

6. I am authorizing the school selection committee or its duly authorized

representative to verify all the documents submitted;

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

November 2023, at Dipolog City.

JOSELITO S. TIZON
(Affiant)
Valid ID#______________
With photo

SUBSCRIBED AND SWORN to before me this ___ day of November 2023, at Dipolog
City.

DOC.NO.

PAGE NO.

BOOK NO.

SERIES OF 2023
 OMNIBUS CERTIFICATION AND VERACITY OF ALL DOCUMENTS SUBMITTED

I, JOEL P. OGOC, of legal age, Filipino, married, a resident of Victoria Country

Homes, Obay, Polanco, Zamboanga del Norte after having been duly sworn in
accordance with law, do hereby depose and state:

That:

7. Each of all documents submitted in satisfaction of requirements for Most

Outstanding Master Teacher position based on the Reform Action in Basic
Education Sector Reform Agenda(BESRA) in authentic copy of original.
Complete and all statements and information provide therein true and
correct;

8. I am authorizing the school selection committee or its duly authorized

representative to verify all the documents submitted;

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

November 2023, at Dipolog City.

JOEL P. OGOC
(Affiant)
Valid ID#______________
With photo

SUBSCRIBED AND SWORN to before me this ___ day of November 2023, at Dipolog
City.

DOC.NO.

PAGE NO.

BOOK NO.

SERIES OF 2023
OMNIBUS CERTIFICATION AND VERACITY OF ALL DOCUMENTS SUBMITTED
I, FE B. ALBERCA, of legal age, Filipino, married, a resident of Turno, Dipolog City,
Zamboanga del Norte after having been duly sworn in accordance with law, do
hereby depose and state:

That:

9. Each of all documents submitted in satisfaction of requirements for Most

Outstanding Teacher position based on the Reform Action in Basic Education
Sector Reform Agenda(BESRA) in authentic copy of original. Complete and
all statements and information provide therein true and correct;

10. I am authorizing the school selection committee or its duly authorized

representative to verify all the documents submitted;

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

November 2023, at Dipolog City.

FE B. ALBERCA
(Affiant)
Valid ID#______________
With photo

SUBSCRIBED AND SWORN to before me this ___ day of November 2023, at Dipolog
City.

DOC.NO.

PAGE NO.

BOOK NO.

SERIES OF 2023
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, MAVITA A. REDILLAS, of legal age, Filipino, widow, a resident of Gulayon,

Dipolog City, Zamboanga del Norte after having been duly sworn in accordance
with law, hereby depose and state:

That I was holder and possessor of OSCA Identification(ID) card issued by Office of
Senior Citizen’s Affairs(OSCA).

That recently, I discovered that my said OSCA ID card was lost, and could not be
found;

That despite effort to recover the same but it was naught. Hence, I considered it
as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
statements and for the purpose of attesting to the loss of the said OSCA ID card.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

November 2023, at Dipolog City.

MAVITA A. REDILLAS
(Affiant)
OSCA ID#5019-Dipolog City
With photo

SUBSCRIBED AND SWORN to before me this ___ day of November 2023, at Dipolog
City.

DOC.NO.

PAGE NO.

BOOK NO.

SERIES OF 2023
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I:ELSA A. CALIOLIO, of legal age, Filipino, married, a resident of 739 Daisy

Road, Guiwan, Zamboanga City after having been duly sworn in accordance
with law, hereby depose and state:

That I was a holder and possessor of Drivers License and its Original Copy of
Official Receipt(OR) issued by the Land Transportation Office(LTO);

That last week, I discovered that my said drivers license and its original
copy of OR were lost;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
drivers license and original copy of OR.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2023, at Dipolog City.

ELSA A. CALIOLIO
 (Affiant)

SSS ID#10-0600764-0
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at

Dipolog City showing her document of identification as indicated above.

Doc. No.

Page No.

Book No.

Series of 2023

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, DHONA ANGELIE H. ROMINGA, of legal age, Filipino, married, a resident

of Poblacion North, Pinan, Zamboanga del Norte, after having been duly
sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of a National Certificate known as NC III

Bookkeeping Certificate issued by TESDA;

That recently, while I was trying to look for the said certificate from my file
where I kept it, I found out that the original document was lost, and could
not be found;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost;

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

foregoing statements and for the purpose of attesting to the loss of the said
certificate.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

November 2023, at Dipolog City.

DHONA ANGELIE H. ROMINGA

 (Affiant)
DepEd ID#5200099
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of November 2023, at

Dipolog City.

Doc. No

Page No

Book No

Series of 2023

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, NELSON S. SAMILIN,JR., of legal age, Filipino,married, a resident of

Olingan, Dipolog City, Zamboanga del Norte after having been duly sworn
in accordance with law, hereby depose and state:

That I am an employee of UNAHCO, Inc.;

That I was a holder and possessor of Official Receipt(OR) issued by Comfort

Zone Inn with OR No.14096 in the amount of P1,300.00.

That recently, I found out that my said receipt was lost;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
receipt.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2023, at Dipolog City.

NELSON S. SAMILIN,JR.
(Affiant)
UMID ID#CRN-0111-9347864-5
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at

Dipolog City.

Doc. No.___

Page No.___

Book No.___

Series of 2023

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, GUILBERT V. JUMALON, of legal age, Filipino,married, a resident of Egot,

Estaka, Dipolog City, Zamboanga del Norte after having been duly sworn in
accordance with law, hereby depose and state:

That I am an employee of W.L. Food Products;

That I was a holder and possessor of W.L. Food Products Delivery Receipt
with Ref#DR001269110 dated 9/18/2023 issued to customer DIPOLOG
CENTRAL TRADING & GEN.MDSE with address of Lacaya St., cor Ranillo St.,
Central, Dipolog City with total amount of P302,005.75.

That recently, I found out that my said receipt was lost;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
receipt.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2023, at Dipolog City.

GUILBERT V. JUMALON
(Affiant)
Philippine ID#8032-5397-1958-2085
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at

Dipolog City.

Doc. No.___

Page No.___

Book No.___

Series of 2023

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ELMAR G. BALINGIT, of legal age, Filipino,married, a resident of Poblacion

South, Polanco, Zamboanga del Norte after having been duly sworn in
accordance with law, hereby depose and state:

That I was a holder and possessor of a Micro-Entrepreneurs Multi-purpose

Cooperative(MEMCO) Passbook with Account No.11-06108-2;
That recently, I found out that my MEMCO Passbook was lost;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
Passbook.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2023, at Dipolog City.

ELMAR G. BALINGIT
(Affiant)
CTC#CCI202121411075
Issued in Poblacion South, Polanco, Zamboanga del Norte
Issued on February 9, 2023
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at

Dipolog City.

Doc. No.___

Page No.___

Book No.___

Series of 2023
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I:EDUARDO D. DAQUE, of legal age, Filipino, married, a resident of Calube,

Sibutad Zamboanga del Norte after having been duly sworn in accordance
with law, hereby depose and state:

That I was a holder and possessor of original Extrajudicial Partition with

Waiver of Rights, Share and Interest notarized by Rubencio B. Legorio per
Doc. No.453, Page No.92, Book No.VIII, Series of 2016 with BIR stamp;

That recently, I discovered that my said document was lost;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
document.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2023, at Dipolog City.

EDUARDO D. DAQUE

(Affiant)

Drivers License#J01-98-026800
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at

Dipolog City showing her document of identification as indicated above.

Doc. No.

Page No.

Book No.

Series of 2023
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I:EDUARDO D. DAQUE, of legal age, Filipino, married, a resident of Calube,

Sibutad Zamboanga del Norte after having been duly sworn in accordance
with law, hereby depose and state:

That I was a holder and possessor of proof of estate tax payments in the
amount P10,800.00 and P8,300.00 dated March 27, 2017 over the estate of
Felicismo Daque under Extrajudicial Partition with Waiver of Rights, Share
and Interest notarized by Rubencio B. Legorio per Doc. No.453, Page No.92,
Book No.VIII, Series of 2016;

That recently, I discovered that my said documents were lost;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
documents.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2023, at Dipolog City.

EDUARDO D. DAQUE

(Affiant)

Drivers License#J01-98-026800
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at

Dipolog City showing her document of identification as indicated above.

Doc. No.

Page No.

Book No.

Series of 2023
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I:BENEDICTO P. RETES, of legal age, Filipino, married, a resident of Minaog,

Dipolog City Zamboanga del Norte after having been duly sworn in
accordance with law, hereby depose and state:

That I was a holder and possessor of Drivers License and its Original Copy of
Official Receipt(OR) issued by the Land Transportation Office(LTO);

That on November 8, 2023, I discovered that my said drivers license and its
original copy of OR were lost;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
drivers license and original copy of OR.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2023, at Dipolog City.

BENEDICTO P. RETES

(Affiant)

Valid ID#______________
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at

Dipolog City showing her document of identification as indicated above.

Doc. No.

Page No.

Book No.

Series of 2023
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I:AMADO P. BAIT-IT, of legal age, Filipino, married, a resident of Canibongan,

Villahermosa, Polanco, Zamboanga del Norte after having been duly sworn
in accordance with law, hereby depose and state:

That I was a holder and possessor of ATM card issued by LandBank of the
Philippines which was used for my pension;

That recently, I discovered that the said ATM card was lost;

That despite effort to recover the same but it was naught. Hence, we
considered it as totally lost.

As such, we are executing this Affidavit of Loss to attest to the truth of the
foregoing statements and for the purpose of attesting to the loss of the said
ATM card.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2023, at Dipolog City.

AMADO P. BAIT-IT
(Affiant)
OSCA ID#21-5007, Polanco, Zamboanga del Norte
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at

Dipolog City.

Doc. No.

Page No.

Book No.
Series of 2023

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, VENUS ROBLE LUCERO, of legal age, Filipino, married, a resident of Isis,

Polanco, Zamboanga del Norte after having been duly sworn in accordance
with law, hereby depose and state:

That I was a holder and possessor of a Philippine Passport with Number

P7719921A issued by the Department of Foreign Affairs;

That in October 2023, I discovered that my passport was lost;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
passport.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2023, at Dipolog City.

VENUS ROBLE LUCERO

(Affiant)
Drivers License#J01-16-003826
With photo
SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at
Dipolog City showing his/her document of identity as indicated above.

Doc. No.___

Page No.___

Book No.___

Series of 2023
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I:ALFONSA V. SECOSANA, of legal age, Filipino, married, a resident of

Dicayas, Dipolog City Zamboanga del Norte after having been duly sworn in
accordance with law, hereby depose and state:

That I was a holder and possessor of Original Copy of Certificate of

Registration(CR) with No.244837935 and Official Receipt(OR) number 1364-
000000256989 for a motor vehicle issued by the Land Transportation
Office(LTO) registered in the name of Romel V. Secosana;

That in October 2023, I discovered that the original copies of CR and OR

were lost;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
original copy of CR and OR.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2023, at Dipolog City.

ALFONSA V. SECOSANA

(Affiant)
OSCA ID#21848-Dipolog City
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at

Dipolog City showing her document of identification as indicated above.

Doc. No.

Page No.

Book No.

Series of 2023
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, MARIA N. ACEBES, of legal age, Filipino, widow, resident of Poblacion, La Libertad, Zamboanga del Norte
after having been duly sworn in accordance with law, hereby depose and state:

That I am the surviving spouse of Elias Acebes, registered owner of a parcel of land, more particularly
described as follows:

A parcel of land known as Lot No.108, Pcs-16050, covered by Transfer Certificate of Title No.T-32556 situated
at Poblacion, La Libertad, Zamboanga del Norte, containing an area of 301 square meters issued by the Register
of Deeds for Zamboanga del Norte.

That the said land was used as collateral for a loan however the bank to which it was loan was closed so I was
able to get the release/cancellation of mortgage from PDIC after I paid fully the loan;

That however the owner’s copy of the title was not turned over to me thus it is gone;

That despite effort to recover the same but it was naught.

That I considered it as totally lost.

That I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for the purpose
of attesting to the loss of the said owner’s copy of Transfer Certificate of Title No.T-32556.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ____th day of _____________ 2023, at
Dipolog City.

MARIA N. ACEBES
(Affiant)
FSCAP ID#01728- La Libertad, ZN
With photo

SUBSCRIBED AND SWORN to before me this ___th day of _________ 2023, at Dipolog City showing the
document of identity as shown above.

DOC.NO. ______

PAGE NO.___

BOOK NO.___

SERIES OF 2023
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ROBERTO ADLAWON CABALIDA, of legal age, Filipino, married, a resident

of Poblacion, Manukan, Zamboanga del Norte after having been duly sworn
in accordance with law, hereby depose and state:

That I was a holder of Official receipt issued by Supreme Court as bail bond
for my spouse Victoria Cabalida docketed as People of the Philippines vs
Victoria Cabalida with Criminal Case No.18820 at Regional Trial Court,
Branch 7, Dipolog City.

That I lost the official due to passage of time;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
original copy of the official receipt.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2023, at Dipolog City.

ROBERTO ADLAWON CABALIDA

(Affiant)
OSCA ID#2022-00495-Manukan,ZN
With photo
SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at
Dipolog City.

Doc. No.

Page No.

Book No.

Series of 2023

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF EXPLANATION

I, RYAN JAY MARAVILLA EGUIA, of legal age, Filipino, married, a resident of Sta Cruz Village,
Relocation Site, Olingan, Dipolog City, Zamboanga del Norte after having been duly sworn in
accordance with law, hereby depose and state:

That I was an applicant of a Philippine Passport which was issued to me and to my name by
Department of Foreign Affairs- General Santos City. However, upon approval and issuance, I
failed to claim my passport from DFA due to the reason that I was not able to travel back to
General Santos City;

That, thereafter, I re-applied for a passport and I mistakenly failed to declare and disclose that
I had a previous application for passport which remains unclaimed;

That, I honestly and in good faith applied for passport so that I could a new passport and could

travel abroad;

As such, I am executing this Affidavit of Explanation to attest to the truth of the foregoing
statements and for the purpose of re-issuance/reclaiming my passport from DFA.
IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2023,
at Dipolog City.

RYAN JAY MARAVILLA EGUIA

(Affiant)
Drivers License#J01-11-001613
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at Dipolog City
showing his/her document of identity as indicated above.
Doc. No.__
Page No.__
Book No.__
Series of 2023

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I:KIM CABANLIT ZAMORAS, of legal age, Filipino, married, a resident of North

Proper, Galas, Dipolog City Zamboanga del Norte after having been duly
sworn in accordance with law, hereby depose and state:

That I was a holder and possessor of Drivers License and its Original Copy of
Official Receipt(OR) issued by the Land Transportation Office(LTO);

That in October 2023, I discovered that my said drivers license and its
original copy of OR were lost;
That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
drivers license and original copy of OR.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2023, at Dipolog City.

KIM CABANLIT ZAMORAS

(Affiant)
UMID ID#CRN-0111-7084271-5
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at

Dipolog City showing her document of identification as indicated above.

Doc. No.

Page No.

Book No.

Series of 2023

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ROSALIE E. JABAL, of legal age, Filipino, married, a resident of Dicayas, Dipolog City, Zamboanga del
Norte after having been duly sworn in accordance with law, hereby depose and state:

That I was a holder and possessor of a Talk’n Text Sim card with number 639813127890;

That recently, I discovered that my said simcard was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said sim card and thereafter requesting replacement of the
same.
IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2023, at
Dipolog City.

ROSALIE E. JABAL
(Affiant)
PRC ID#1918802 valid until 1/28/2025
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023 by above-named person
showing her document of identity as shown above, at Dipolog City.

Doc. No.

Page No.

Book No.

Series of 2023

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I:CHARLITA ARONDA OCUPE, of legal age, Filipino, married, a resident of

Poblacion North, Polanco, Zamboanga del Norte after having been duly
sworn in accordance with law, hereby depose and state:

That I was a holder and possessor of ATM card issued by LandBank of the
Philippines with account/card number 6031310005100308777 which was
used for benefits of 4Ps of DSWD;

That recently, I discovered that the said ATM card was lost;
That despite effort to recover the same but it was naught. Hence, we
considered it as totally lost.

As such, we are executing this Affidavit of Loss to attest to the truth of the
foregoing statements and for the purpose of attesting to the loss of the said
ATM card.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2023, at Dipolog City.

CHARLITA ARONDA OCUPE

(Affiant)
DSWD 4Ps ID#097210030-0473-0187
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at

Dipolog City.

Doc. No.

Page No.

Book No.

Series of 2023

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF NON-CONTRIBUTION OF SSS PREMIUM

I, JEFFREY C. PADILLA, Filipino, of legal age, single, and a resident of San

Antonio, Katipunan, Zamboanga del Norte after having been duly sworn in
accordance with law, hereby depose and state:
That I was an employee of 3C’S MEATSHOP MERCHANDISE, with address of
Dapitan City since May 2021 until May 2022 as BUTCHER;

That I was absorbed by CHA MEATSHOP, with address of Barra, Dipolog City
after closure of 3C’S MEATSHOP MERCHANDISE since May 2022 until
present as BUTCHER;

That both 3C’S MEATSHOP MERCHANDISE and CHA MEATSHOP are owned
by the same employer;

That my employer has not been remitting my SSS premium contributions on

the reason that the said business is just small and the employees are just
few thus covered by Barangay Micro Business Enterprise(BMBE) law;

That I am executing this to support my employment record and experience;

That I am executing this Affidavit to attest to the truth of the foregoing

statements.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2023, at Dipolog City.

JEFFREY C. PADILLA
(Affiant)
Pag-ibig MID ID#1211-6608-5374
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at

Dipolog City showing his/her document of identity with its number indicated
above.

Doc. No.__
Page No.__
Book No.__
Series of 2023
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF NON-CONTRIBUTION OF SSS PREMIUM

I, MARK DALMAN WINTERS, Filipino, of legal age, single, and a resident of

Poblacion, Jose Dalman, Zamboanga del Norte after having been duly
sworn in accordance with law, hereby depose and state:

That I am an employee of EL DOLCE’S MEATSHOP, with address of Barra,

Dipolog City;

That I am an employee of said meatshop since August 29, 2019 up to

present as BUTCHER;

That my employer has not been remitting my SSS premium contributions on

the reason that the said business is just small and the employees are just
few thus covered by Barangay Micro Business Enterprise(BMBE) law;

That I am executing this to support my employment record and experience;

That I am executing this Affidavit to attest to the truth of the foregoing

statements.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2023, at Dipolog City.

MARK DALMAN WINTERS

(Affiant)
Philippine ID#6125-1845-0143-9075
With phot

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at

Dipolog City showing his/her document of identity with its number indicated
above.

Doc. No.__
Page No.__
Book No.__
Series of 2023
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, MARGIE B. VIDAL-MURRO, Filipino, of legal age, married, and a resident of

Balintawak St., Barra Isabel, Dipolog City, Zamboanga del Norte after
having been duly sworn in accordance with law, hereby depose and state:

That I am representative of ZN Agri-Technical Institute, Inc. and possessor

of Income Tax Returns and Financial Statements CY 2022 of the said
enterprise;

That recently, I found out that the said documents were lost, I tried to locate
the documents but it was really lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
documents.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2023, at Dipolog City.

MARGIE VIDAL MURRO

(Affiant)
Phil ID#3813-4683-6035-1267
With phot

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at

Dipolog City showing his/her document of identity with its number indicated
above.

Doc. No.__
Page No.__
Book No.__
Series of 2023
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, KHIAN D. PABALAY, Filipino, of legal age, single, and a resident of Dugwell,

Sta. Isabel, Dipolog City, Zamboanga del Norte after having been duly
sworn in accordance with law, hereby depose and state:

That I was a holder and possessor of receipt issued by Palawan Pawnshop-

Sta.Filomena, Dipolog City Branch for pawned jewelry with PT#14715-One
Pair of TCG Creolla Earrings 1 pc lock lossend Aprrox.3.76/18k and
PT#14651-One Pair YG Creolla Earrings w/Deformity Approx.3.56/18k;

That recently, I found out that my receipts were lost, I tried to locate the
receipts but it was really lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
receipts.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2023, at Dipolog City.

KHIAN D. PABALAY
(Affiant)
Driver’s License#J01-22-300037
With phot

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at

Dipolog City showing his/her document of identity with its number indicated
above.

Doc. No.__
Page No.__
Book No.__
Series of 2023

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, MARY ANN POSPOS ADLAWON, of legal age, Filipino, single, a resident of

Purok 2, Ebarle, Josefina, Zamboanga del Sur after having been duly sworn
in accordance with law, hereby depose and state:
That I was a holder and possessor of a Philippine Passport issued by the
Department of Foreign Affairs;

That on December 13, 2022, I discovered that my passport was lost;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
passport.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2023, at Dipolog City.

MARY ANN POSPOS ADLAWON

(Affiant)
Philippine ID#3079-2687-5125-8209
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at

Dipolog City showing his/her document of identity as indicated above.

Doc. No.___

Page No.___

Book No.___

Series of 2023
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I:JEROME FERNANNDEZ ESTERA, of legal age, Filipino, married, a resident of

Gulayon, Dipolog City Zamboanga del Norte after having been duly sworn
in accordance with law, hereby depose and state:

That I was a holder and possessor of Drivers License and its Original Copy of
Official Receipt(OR) issued by the Land Transportation Office(LTO);

That in February 2023, I discovered that my said drivers license and its
original copy of OR were lost;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
drivers license and original copy of OR.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2023, at Dipolog City.

JEROME FERNANDEZ ESTERA

(Affiant)
Philippine ID#6458-3046-3792-8495
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at

Dipolog City showing her document of identification as indicated above.

Doc. No.

Page No.

Book No.

Series of 2023
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, RITO Q. PAUSAL, of legal age, Filipino, married, a resident of Lower Irasan, Roxas, Zamboanga del
Norte after having been duly sworn in accordance with law, hereby depose and state:

That I was a holder and possessor of a claim slip issued by Mandarin Hardware & Auto Supply with
address of Dipolog City for the items I will claim from purchased items in their Warehouse in Galas,
Dipolog City. That the official receipts for the items I purchased is Sales Invoice No.436174A.

That yesterday the said claim slip was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said claim slip.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2023, at
Dipolog City.

RITO Q. PAUSAL
(Affiant)
PRC ID#1542788
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at Dipolog City showing
his/her document of identity indicated above.
Doc. No.__
Page No.__
Book No.__
Series of 2023
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT

I, JOSE B. SALAC, of legal age, Filipino, married, with office address of Municipal Hall, East Poblacion,
Rizal, Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and
state:

That I am the incumbent Vice Mayor of Rizal, Zamboanga del Norte;

That on October 13, 2023, I received solicitation letter coming from Elmer J. Garcia, candidate for
Punong Barangay of Brgy. Damasing, Rizal, Zamboanga del Norte; Farah Faith Albon, candidate for SK
Chairperson of the same barangay; third person in the name of Bernabe Bermudo, who introduced
himself as Barangay Coordinator and at the same time he runs for Barangay Kagawad of the same
barangay;

That they solicited for money and I donated my personal money of P3,500.00;

That the said money was received by ELMER J. GARCIA.

That I attached copy of the solicitation letter.

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

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2023, at
Dipolog City.

JOSE B. SALAC
(Affiant)
Valid ID#___________________________________
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at Dipolog City showing
his/her document of identity indicated above.
Doc. No.__
Page No.__
Book No.__
Series of 2023
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, CHILA M. PACARO, of legal age, Filipino, single, a resident of Purok Kawayan, Turno, Dipolog City,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I was a holder and possessor of an Automated Teller Machine(ATM) card issued by Land Bank of
the Philippines (LBP) Dipolog City Branch which is my payroll ATM card as employee of DPWH.

That recently, I discovered that the LBP ATM card was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said LBP ATM card and thereafter requesting replacement
thereon.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2023, at
Dipolog City.

CHILA M. PACARO
(Affiant)
DPWH ID#14-JO-0660
With photo
SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at Dipolog City showing
his/her document of identity indicated above.
Doc. No.__
Page No.__
Book No.__
Series of 2023

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I:REMART GARCIA LADEZA, of legal age, Filipino, single, a resident of

Poblacion, Tampilisan Zamboanga del Norte after having been duly sworn
in accordance with law, hereby depose and state:

That I was a holder and possessor of Drivers License and its Original Copy of
Official Receipt(OR) issued by the Land Transportation Office(LTO);

That yesterday, I discovered that my wallet containing the said drivers

license and its original copy of OR was lost;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
drivers license and original copy of OR.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2023, at Dipolog City.

REMART GARCIA LADEZA

 (Affiant)
Valid ID#________________
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at

Dipolog City showing her document of identification as indicated above.

Doc. No.

Page No.

Book No.

Series of 2023

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ANDRESA ANIǸON SAVERON of legal age, Filipino, married, a resident of Zamoras

Compound, Miputak, Dipolog City, Zamboanga del Norte after having been duly sworn in
accordance with law, hereby depose and state:

That I was a possessor and holder of Senior citizen’s identification card issued by the Office of
the Senior Citizen’s Affairs(OSCA).
That recently my said Senior citizen’s identification card was lost;

That despite effort to recover the same but it was naught.

Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements
and for the purpose of attesting to the loss of the said Senior citizen’s identification card.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2023,
at Dipolog City.

ANDRESA ANIǸON SAVERON

(Affiant)

Valid ID#____________________

With photo

SUBSCRIBED AND SWORN to before me showing his/her document of identification as shown

above this ___ day of _________ 2023, at Dipolog City.

Doc. No

Page No

Book No

Series of 2023
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I:NICANOR NAQUILA, of legal age, Filipino, a resident of Polanco,Zamboanga

del Norte after having been duly sworn in accordance with law, hereby
depose and state:

That I was a holder and possessor of Drivers License and its Original Copy of
Official Receipt(OR) issued by the Land Transportation Office(LTO) and
Senior Citizen’s ID issued by Office of the Senior Citizen’s Affairs(OSCA);

That today, I discovered that my wallet containing the said Senior’s Citizens
ID and driver’s license and its original copy of OR was lost;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
senior citizen’s ID and drivers license and original copy of OR.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2023, at Dipolog City.

NICANOR NAQUILA
(Affiant)
Valid ID#________________
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at

Dipolog City showing her document of identification as indicated above.

Doc. No.

Page No.

Book No.

Series of 2023
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, MARLINA BAJAO ELUMBARING, of legal age, Filipino, widow, a resident of

Obay, Polanco, Zamboanga del Norte after having been duly sworn in
accordance with law, hereby depose and state:

That I was a holder and possessor of a Philippine Passport issued by the

Department of Foreign Affairs;

That recently, I discovered that my passport was lost;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
passport.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2023, at Dipolog City.

MARLINA BAJAO ELUMBARING

(Affiant)
Philippine ID#5829-1865-0410-3563
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at

Dipolog City showing his/her document of identity as indicated above.

Doc. No.___

Page No.___

Book No.___

Series of 2023
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I:RONALDO PALACIO, of legal age, Filipino, single, a resident of Banbanan,

Pres MA. Roxas Zamboanga del Norte after having been duly sworn in
accordance with law, hereby depose and state:

That I was a holder and possessor of Drivers License and its Original Copy of
Official Receipt(OR) issued by the Land Transportation Office(LTO);

That yesterday, I discovered that the said drivers license and its original
copy of OR was lost;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
drivers license and original copy of OR.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2023, at Dipolog City.

RONALDO PALACIO
(Affiant)
Valid ID#________________
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at

Dipolog City showing her document of identification as indicated above.

Doc. No.

Page No.

Book No.
Series of 2023

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF HEIRSHIP and OWNERSHIP

I, RUFO ABITONA BUCA, of legal age, Filipino, married, a resident of Sinaman, Dipolog City,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am one of the heirs of Basilio Abitona;

That Heirs of Basilio Abitona is the owner of parcel of land known as Lot 5734-A,Psd-09-023533
covered by Transfer Certificate of Title No.T-12336 located at Galas, Dipolog City containing an area of
7,097 square meters;

That the Heirs of Basilio are namely: Perfecta Buca;Elena A. Soliva; Prisilla A. Refugio; Irene A. Ramos;
Adelaida A. Bustalino; Teodosia A. Kishna; and Meldrid A. Balido. That these heirs are already dead;

That they were survived by undersigned, Lucio A. Buca, Nelson A. Ramos, Zenaida Ramos-Bala, Shirley
A. Ramos, Rodolfo A. Soliva, Julieta A. Soliva Maglangit, Laura A. Soliva Daniel, Elna Soliva Sebpao,
Nino A. Soliva, Maria Berlin A. Soliva, Arlene A. Bustaliǹo, Arnida A. Bustaliǹo, Ronnel A. Refugio, Ruth
Kishna Alburo, Dorothy Kishna Gargar, Milven A. Balido, Ramil A. Balido, Dionesa Buca Soliva, Fidela
Buca Ragas, Leandro A. Buca, Ruel A. Buca, Arnold A. Bustaliǹo, Kathy Kishna Duran and Eddie A.
Bustaliǹo;

That the abovementioned persons are the only heirs of Basilio Abitona and there are no other heirs
except the abovementioned persons;

That we exercise all acts of ownership over the said parcel of land as well as we have all the rights to
utilize and dispose the same;

That I hereby warrant that there are no liens or encumbrances over the said parcel of land as we have
full control and ownership of the same;

That I am duly authorized to dispose the said parcel of land as I am equipped with all necessary
powers of attorney from all other heirs who are not present or living in Dipolog City;

That I am executing this Affidavit to attest to the truth of the foregoing statements.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2023, at
Dipolog City.
 RUFO ABITONA BUCA
(Affiant)
PRC ID#0041543 valid until 4/19/2024
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at Dipolog City showing
his/her document of identity indicated above.
Doc. No.__
Page No.__
Book No.__
Series of 2023

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, JOYCE MARIE Q. DOROMAL, of legal age, Filipino, single, a resident of Purok 1, Poblacion, La
Libertad, Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose
and state:

That I was a holder and possessor of an Automated Teller Machine(ATM) card issued by Philippine
National Bank (PNB) Dipolog City Branch with card/account number 412810048831.

That recently, I discovered that the PNB ATM card was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said PNB ATM card and thereafter requesting replacement
thereon.
IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2023, at
Dipolog City.

JOYCE MARIE Q. DOROMAL

(Affiant)
Philippine ID#2458-9601-3648-7915
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at Dipolog City showing
his/her document of identity indicated above.
Doc. No.__
Page No.__
Book No.__
Series of 2023

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, JOSELYN GARCIA BONGCAC, of legal age, Filipino, married, and with address
of Madison County, Dicayas, Dipolog City, Zamboanga del Norte after having been
duly sworn in accordance with law, hereby depose and state:

That I was a holder and possessor of Official Receipt with number 0105 in the
amount of P2,900.00 issued by Pantaleon A. Lubrico Homeowners Association,
Inc.;

That recently I discovered that my said document was lost;

That despite effort to recover the same but it was naught. Hence, I considered it
as totally lost.
As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
statements and for the purpose of attesting to the loss of the said document.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2023, at Dipolog City. massive

JOSELYN GARCIA BONGCAC

(Affiant)
PRC ID#0584822 valid until 06/23/2024

With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at Dipolog
City showing his/her document of identity as indicated above.

Doc. No.___

Page No.___

Book No.___

Series of 2023

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, MARIADISE C. DELA PEǸA, of legal age, Filipino, married, and with address of
La Concepcion, Sindangan, Zamboanga del Norte after having been duly sworn in
accordance with law, hereby depose and state:

That I was a holder and possessor of document Extrajudicial Settlement among

Heirs notarized by Atty Prim Abarquez III per notarial register Doc. No.437, Page
No. 18, Book No.85, Series of 2014 which was stamped by Bureau of Internal
Revenue at the back portion;

That recently I discovered that my said document was lost;

That despite effort to recover the same but it was naught. Hence, I considered it
as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
statements and for the purpose of attesting to the loss of the said document.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2023, at Dipolog City. massive

MARIADISE C. DELA PEǸA

(Affiant)
Phil ID#3942-7913-8246-1897

With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at Dipolog
City showing his/her document of identity as indicated above.

Doc. No.___

Page No.___

Book No.___

Series of 2023

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS
I, LORNA CAMPOS BASILIO, of legal age, Filipino, married, a resident of
Poblacion South, Polanco, Zamboanga del Norte after having been duly
sworn in accordance with law, hereby depose and state:

That I was a holder and possessor of Unified Multipurpose

Identification(UMID) Card issued by the Government Service Insurance
System(GSIS);

That recently I discovered that my UMID was lost;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
UMID.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2023, at Dipolog City.

LORNA CAMPOS BASILIO

(Affiant)
Philippine Passport No.P0223353C
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at

Dipolog City showing his/her document of identity as indicated above.

Doc. No.___

Page No.___

Book No.___

Series of 2023

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x
 AFFIDAVIT OF LOSS

I, CHERRY E. SANICO, of legal age, Filipino, married, a resident of Dugwell, Sta. Isabel, DIpolog
City, Zamboanga del Norte after having been duly sworn in accordance with law, hereby
depose and state:

That I was a holder/possessor of Certificate of Full Payment and official receipts(ORs) on

payments issued by Rural Bank of Dipolog, Inc., on mortgaged land covered by TCT No.T-30271
located at Poblacion, Polanco, Zamboanga del Norte;

That recently, I discovered that the said ORs and certificate were lost and I tried to locate the
said certificate but I could not find it;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements
and for the purpose of attesting to the loss of the said certificate of full payment and ORs.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ____ day of __________
2023, at Dipolog City.

CHERRY E. SANICO
(Affiant)
UMID ID#CRN-0113-0369830-9
With photo

SUBSCRIBED AND SWORN to before me this ___ day of ________ 2023, at Dipolog City.

Doc. No

Page No

Book No

Series of 2023

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT
I, ANNABELLE SAGARIO DIHAYCO, of legal age, Filipino, married, a resident
of Brgy. Dos, Katipunan, Zamboanga del Norte after having been duly
sworn in accordance with law, hereby depose and state:

That I am the mother of RHIANNE MAE SAGARIO DIHAYCO;

That my said child’s gender was mistakenly entered as MALE;

That in truth and fact, my said child has a gender of FEMALE;

That she is examined and found that she has a gender of FEMALE;

That I looked for medical records at the hospital however the medical
records was not found;

That I hereby attest the truthfulness of her gender which should be FEMALE;

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

statements.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2023, at Dipolog City.

ANNABELLE SAGARIO DIHAYCO

(Affiant)
Voters ID#7203-0005A-I1582ASD20000
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at

Dipolog City showing his/her document of identity as indicated above.

Doc. No.___

Page No.___

Book No.___

Series of 2023

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x
 JOINT-AFFIDAVIT

WE: GUADALUPE P. SUMAGANG; FLORENDA T. BUBURAN; GLEANA R.

MAYORMITA; ARLENE A. MARAVILLAS; MARIA NELMA C. CIMAFRANCA;
RESANERIE C. ARCENO; all of legal age; all Filipinos; all married; all with
office address of Dangi Elementary School, Dangi, Polanco, Zamboanga del
Norte; after having been duly sworn in accordance with law, hereby depose
and state:

That we are teaching staff of Dangi Elementary School with address of

Dangi, Polanco, Zamboanga del Norte;

That we execute this affidavit to support our School Head Rogelio A. Ocamia
and to belie the allegations made in the Notice to Explain issued by the
Schools Division Superintendent Sir Roy C. Tuballa, EMD, JD, CESO VI;

That we will specifically state that:

That we are all members of the Bids and Awards Committee including
canvasser and inspector;

That we vehemently deny that we were ever threatened by Mr. Rogelio A.

Ocamia, our School Head relative to our functions as signatories of our
liquidation reports or BAC related papers including the usage of Local School
Fund which was not ever bloated neither the reports contained false
information; That we attest that the reports submitted to the division were
all valid and contained truthful informations;

That we also deny that Mr. Rogelio A. Ocamia forced us to contribute for
expenses. That truthfully, our school did not any MOOE allocation since
January 2023 so our entire school staff had a meeting and we all voted that
we will contribute so that our electricity will not be cut. It was our own
volition to contribute money, not Mr. Rogelio A. Ocamia, because we knew
we are serving a remote school and we must serve our students despite
lack of school funds. Also we all knew that we would be reimbursed once the
MOOE will be downloaded to the school.

That also, we did not contribute for the school graduation and other
expenses.

That Mr. Rogelio A. Ocamia did not ever threatened us in any manner

That we execute this to support our School Head Rogelio A. Ocamia and to
request the good Schools Division Superintendent to dismiss the allegations
againt the former for it is baseless and very far from the truth.

That we are executing this Affidavit to attest to the truth of the foregoing
statements.
IN WITNESS WHEREOF, we have hereunto affixed our signatures this ___ day
of __________ 2023, at Dipolog City.

GUADALUPE P. SUMAGANG; FLORENDA T. BUBURAN;

Affiants
PRC ID#0694837/PRC ID#0411777

GLEANA R. MAYORMITA; ARLENE A. MARAVILLAS;

Affiants
TIN#451-206-149/UMID ID#CRN-006-0040-1220-5

MARIA NELMA C. CIMAFRANCA; RESANERIE C. ARCENO

Affiants
UMID ID#CRN-006-0174-7010-4/UMID ID#CRN-006-0173-7875-2

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at

Dipolog City.

Doc. No.___

Page No.___

Book No.___

Series of 2023
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, RICHIE TOME CAYONGCONG, of legal age, Filipino, single, a resident of

Purok Bucana, Canlucani, Dapitan City, Zamboanga del Norte after having
been duly sworn in accordance with law, hereby depose and state:

That I was a holder and possessor of Unified Multipurpose

Identification(UMID) Card issued by the Government Service Insurance
System(GSIS);

That recently I discovered that my UMID was lost;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
UMID.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2023, at Dipolog City.

RICHIE TOME CAYONGCONG

 (Affiant)
Philippine ID#5426-0365-8647-2945
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at

Dipolog City.

Doc. No.___

Page No.___

Book No.___

Series of 2023

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, PERCIVAL J. ABO, of legal age, Filipino, married, a resident of Purok Cacao, Minaog, Dipolog City,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am the spouse of Genevie Echavez Abo, a graduate of St. Peter’s College, Iligan City;

That I was holder and possessor of my spouse’s Diploma and Transcript of Records(TOR) as a graduate
of said school;

That during Typhoon Sendong in December 2012 our house was affected by great flood and during
the said typhoon the original copies of my spouse’s documents were soaked and destroyed by water
including the Diploma and TOR thus the original copy of my wife’s Diploma and TOR were lost, and
could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;
As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said documents.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2023, at
Dipolog City.

PERCIVAL J. ABO
(Affiant)
Phil.ID#4573-1468-1071-9563
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at Dipolog City showing
his/her document of identity as indicated above.

Doc. No.

Page No.

Book No.

Series of 2023

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, MARJUN AMADIO DELOS REYES, of legal age, Filipino, married, a resident

of South Baybay, Galas, Dipolog City, Zamboanga del Norte after having
been duly sworn in accordance with law, hereby depose and state:

That I was a holder and possessor of a Philippine Passport issued by the

Department of Foreign Affairs;

That recently, I discovered that my passport was lost;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.
As such, I am executing this Affidavit of Loss to attest to the truth of the
foregoing statements and for the purpose of attesting to the loss of the said
passport.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2023, at Dipolog City.

MARJUN AMADIO DELOS REYES

(Affiant)
Valid ID#__________________
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at

Dipolog City showing his/her document of identity as indicated above.

Doc. No.___

Page No.___

Book No.___

Series of 2023

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, MARVIE A. TUBAT, of legal age, Filipino, married, a resident of Larayan, Dapitan City, Zamboanga del
Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am the brother of J-E PORFERIO CENAS, a graduate of Andres Bonifacio College, Dipolog City;

That I was holder and possessor of my brother’s Diploma and Transcript of Records(TOR) as a
graduate of said school;
That in 2014 our house wherein the said documents were kept was razed with fire thus the original
copy of J-E Porferio Cenas’ Diploma and TOR were lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said documents.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2023, at
Dipolog City.

JOSELITO PORFERIO CENAS

(Affiant)
PNP ID#22A2100063
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at Dipolog City showing
his/her document of identity as indicated above.

Doc. No.

Page No.

Book No.

Series of 2023

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I:JEFFREY Q. LIMCUANDO, of legal age, Filipino, married, a resident of

Anastacio, Polanco, Zamboanga del Norte after having been duly sworn in
accordance with law, hereby depose and state:

That I was a holder and possessor of Drivers License and its Original Copy of
Official Receipt(OR) issued by the Land Transportation Office(LTO);
That yesterday, I discovered that the said drivers license and its original
copy of OR was lost;

That despite effort to recover the same but it was naught. Hence, we
considered it as totally lost.

As such, we are executing this Affidavit of Loss to attest to the truth of the
foregoing statements and for the purpose of attesting to the loss of the said
drivers license and original copy of OR.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2023, at Dipolog City.

JEFFREY Q. LIMCUANDO
(Affiant)
DL#N02-95-299565
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at

Dipolog City showing her document of identification as indicated above.

Doc. No.

Page No.

Book No.

Series of 2023

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF NO OBJECTION

I, PONCIANO A. DIMALANTA, of legal age, Filipino, married to Blesilda

Amatong, a resident of Turno, Dipolog City, Zamboanga del Norte after
having been duly sworn in accordance with law, hereby depose and state:
That I am the owner of portion of land denominated as Lot 4513-C-4-C-1
containing an area of 440 square meters located at Isis, Polanco,
Zamboanga del Norte pursuant to Deed of Absolute of Sale of a Parcel of
Land notarized by Dario M. Mandantes with Doc. No.812, Page No.45, Book
No.XX, Series of 2021;

That as adjacent landowner,I interposed no objection to the application for

title of Amancio C. Jarmin over parcel of land subject in FPA -097201-880
because the said parcel of land is no longer a road right of way and also we
have another area set as road right of way;

That the said area claimed by Amancio C. Jarmin is no longer considered as

road right of way and he has claimed over it;

That as such I hereby attest my non-objection over the claim of Mr. Amancio
C. Jarmin and his application for free patent.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2023, at Dipolog City.

PONCIANO A. DIMALANTA
(Affiant)
OSCA ID#16552-Dipolog City
With photo

Marital consent:

BLESILDA DIMALANTA
OSCA ID#15546-Dipolog City

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at

Dipolog City showing his/her document of identity as indicated above.

Doc. No.___

Page No.___

Book No.___

Series of 2023
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, RHOCHINE SHYNE DORIMON RATIFICAR, of legal age, Filipino, single, a

resident of Mibang, Sta. Filomena, Dipolog City, Zamboanga del Norte after
having been duly sworn in accordance with law, hereby depose and state:

That I was a holder and possessor of a Professional Regulation

Commission(PRC) Identification card(ID) issued by the PRC, Unified
Multipurpose ID(UMID) issued by GSIS and Pag-ibig ID issued by Pag-ibig;

That on August 20, 2023, I discovered that my Professional Regulation

Commission(PRC) Identification card(ID) issued by the PRC, Unified
Multipurpose ID(UMID) issued by GSIS and Pag-ibig ID issued by Pag-ibig
were lost;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
Professional Regulation Commission(PRC) Identification card(ID) issued by
the PRC, Unified Multipurpose ID(UMID) issued by GSIS and Pag-ibig ID
issued by Pag-ibig.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2023, at Dipolog City.

RHOCHINE SHYNE DORIMON RATIFICAR

(Affiant)
Deped Employee ID#1700049-Zamboanga del Norte
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at

Dipolog City showing his/her document of identity as indicated above.
Doc. No.___

Page No.___

Book No.___

Series of 2023

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, GLEZA R. JARAPAN, of legal age, Filipino, single, a resident of Guinles, Polanco, Zamboanga del Norte
after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of an Automated Teller Machine(ATM) card issued by Land Bank of
the Philippines(LBP) Dipolog City Branch with card/account number 6031310005100291601.

That recently, I discovered that the LBP ATM card was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said LBP ATM card and thereafter requesting replacement
thereon.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2023, at
Dipolog City.

GLEZA R. JARAPAN
(Affiant)
DSWD ID#097210001-999814104
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2023

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT

I, MARBIN ALAP-AP TUBAT, of legal age, Filipino, single, a resident of Liyang, Dapitan City, Zamboanga
del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am the document owner of the following documents:

6. Diploma issued by Jose Rizal Memorial State University, Dapitan City Campus as graduate of
Bachelor of Secondary Education;

7. Transcript of Records issued by Jose Rizal Memorial State University, Dapitan City Campus;

8. Certificate issued by EFSET;

9. Certification dated 4th day of September 2023 issued by Department of Education;

10. TESOL CERTIFICATE;

That the abovesaid documents are faithful reproduction of the original copies issued by government
agencies of the Philippines.

As such, I am executing this Affidavit to attest to the truth of the foregoing statements.
IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2023, at
Dipolog City.

MARBIN ALAP-AP TUBAT

(Affiant)
PRC ID#1403540 valid until 1/26/2024
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at Dipolog City showing
his/her document of identity as indicated above.

Doc. No.

Page No.

Book No.

Series of 2023

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT

I, GENEVIE E. ABO, of legal age, Filipino, married, a resident of Sta.Filomena,Dipolog City, Zamboanga
del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am the document owner of the following documents:

11. Transcript of Records issued by Colegio de San Francisco Javier;

12. Certification issued by Department of Education dated 4th day of September 2023;

13. Certificate of Training issued by TESDA, Region IX dated 30th day of August 2023;

14. Certificate issued by EFSET;

15. TESOL CERTIFICATE;

16. Diploma issued by Mindanao State University dated March 6, 2019;

17. Certificate of Participation issued by Southeast Asian Institute of Educational Training, Inc.
dated September 29, 2019;

18. Certificate of Live Birth issued by Philippine Statistics Authority;

 19. Certificate of Marriage with Percival J. Abo issued by Philippine Statistics Authority.

That the abovesaid documents are faithful reproduction of the original copies issued by government
agencies of the Philippines.

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

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2023, at
Dipolog City.

GENEVIE E. ABO
(Affiant)
Umid ID#CRN-011-1289-7319-9
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at Dipolog City showing
his/her document of identity as indicated above.

Doc. No.

Page No.

Book No.

Series of 2023

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, JOSELITO PORFERIO CENAS, of legal age, Filipino, married, a resident of Potungan, Dapitan City,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am the brother of J-E PORFERIO CENAS, a graduate of Andres Bonifacio College, Dipolog City;
That I was holder and possessor of my brother’s Diploma and Transcript of Records(TOR) as a
graduate of said school;

That in 2014 our house wherein the said documents were kept was razed with fire thus the original
copy of J-E Porferio Cenas’ Diploma and TOR were lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said documents.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2023, at
Dipolog City.

JOSELITO PORFERIO CENAS

(Affiant)
PNP ID#22A2100063
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at Dipolog City showing
his/her document of identity as indicated above.

Doc. No.

Page No.

Book No.

Series of 2023

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS
I, JEAN ROSE BANSIL CALACLAN, of legal age, Filipino, single, a resident of
Purok Guava, Maria Cristina, Dapitan City, Zamboanga del Norte after
having been duly sworn in accordance with law, hereby depose and state:

That I was a holder and possessor of a Philippine Passport issued by the

Department of Foreign Affairs;

That in January 2023, during flood in our place, I discovered that my

passport was lost;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
passport.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2023, at Dipolog City.

JEAN ROSE BANSIL CALACLAN

(Affiant)
Voters ID#7202-0226B-A1296MBC20000-0
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at

Dipolog City showing his/her document of identity as indicated above.

Doc. No.___

Page No.___

Book No.___

Series of 2023

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS
I, MICHELLE MAY P. GERONILLA, of legal age, Filipino, single, a resident of
Upper Turno, Dipolog City, Zamboanga del Norte, after having been duly
sworn in accordance with law, hereby depose and state:

That I am the keeper of the Business Permit and Business Plate of TRIX BAR
AND GRILL located at Velasco St., Dipolog City, issued by LGU-Dipolog City,
registered under my name;

That recently, while I was trying to look for the said business permit and
plate from where I kept it, I found out that the business plate and permit
were lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost;

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

foregoing statements and for the purpose of attesting to the loss of the said
business permit and plate.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2023, at Dipolog City.

MICHELLE MAY P. GERONILLA

(Affiant)
TIN#947-045-079
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at

Dipolog City showing his/her document of identity as indicated above.

Doc No. _____

Page No. _____
Book No. ____
Series of 2023
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I:CHRIST GLESONSYL C. DYAMIEL, of legal age, Filipino, married, a resident

of Sta. Isabel, Dipolog City, Zamboanga del Norte after having been duly
sworn in accordance with law, hereby depose and state:

That I was a holder and possessor of Original Copy of Certificate of

Registration(CR) for motor vehicle with Engine No.E3R2E-0860511, CR
No.251915523 issued by the Land Transportation Office(LTO);

That recently, I discovered that the said original copy of CR was lost;

That despite effort to recover the same but it was naught. Hence, we
considered it as totally lost.

As such, we are executing this Affidavit of Loss to attest to the truth of the
foregoing statements and for the purpose of attesting to the loss of the said
original copy of CR.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2023, at Dipolog City.

CHRIST GLESONSYL C. DAYMIEL

(Affiant)
Drivers License#J01-10-003573
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at

Dipolog City showing her document of identification as indicated above.

Doc. No.

Page No.

Book No.

Series of 2023
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I:IAN TAPALES TEVES, of legal age, Filipino, married, a resident of

Turno,Dipolog City, Zamboanga del Norte after having been duly sworn in
accordance with law, hereby depose and state:

That I was a holder and possessor of Drivers License and its Original Copy of
Official Receipt(OR) issued by the Land Transportation Office(LTO);

That yesterday, I discovered that the said drivers license and its original
copy of OR was lost;

That despite effort to recover the same but it was naught. Hence, we
considered it as totally lost.

As such, we are executing this Affidavit of Loss to attest to the truth of the
foregoing statements and for the purpose of attesting to the loss of the said
drivers license and original copy of OR.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2023, at Dipolog City.

IAN TAPALES TEVES

(Affiant)
Philippine ID#3821-8739-7028-4167
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at

Dipolog City showing her document of identification as indicated above.

Doc. No.
Page No.

Book No.

Series of 2023

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF JUSTIFICATION

I, ADELAIDA NERI RAZO, of legal age, Filipino, widow of Uldarico Razo, a resident of Poblacion,
Baliguian, Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose
and state:

That I am the surviving spouse of late SPO1 Uldarico B. Razo;

That I was required to submit our wedding photographs, one of the requirements, to support my
claim for transfer of pension claim;

That I could not submit our wedding photographs because on the date of our wedding August 29,
1987 we asked a photographer to took our wedding photo, which at that time was very expensive,
however upon securing our copy I and my spouse were informed that our photograph was not
developed because the film got burned.

That I express regret not able to comply the said requirement.

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

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2023, at
Dipolog City.

ADELAIDA NERI RAZO

(Affiant)
Drivers License#J07-19-006960 valid until 2024/09/01
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at Dipolog City showing
his/her document of identity as indicated above.
Doc. No.

Page No.

Book No.

Series of 2023

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, SERGIO NACARIO BAQUILLER, of legal age, Filipino, married, a resident of Turno, Dipolog City,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a high school graduate at Zamboanga del Norte National High School, with address at
Turno, Dipolog City;

That I was holder and possessor of a Diploma as a graduate of said school;

That recently I discovered that the original copy of my Diploma was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said document.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2023, at
Dipolog City.
 SERGIO NACARIO BAQUILLER, JR
(Affiant)
Drivers License#J01-22-300902
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at Dipolog City showing
his/her document of identity as indicated above.

Doc. No.

Page No.

Book No.

Series of 2023
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, JONGKER BERO DURIAS, of legal age, Filipino, single, a resident of Bagacay, Sibutad,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I was holder and possessor of AFPMBAI 10 Year Endowment with Policy Number 201309105;

That upon the death of my father I tried to look for the said policy contract;

That however I found it was lost;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said policy contract.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2023, at
Dipolog City.

JONGKER BERO DURIAS

(Affiant)
PNP ID#23E2500446
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at Dipolog City.

Doc. No.

Page No.

Book No.

Series of 2023
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, GINYMFA S. ENTRINA, of legal age, Filipino, married, a resident of Gunyan, Siayan, Zamboanga
del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am an owner of a cellular phone with Sim Card with Number 09362217747(TM) ;

That my said cellular phone with said sim card was used in all important transactions;

That recently my said phone was lost;

That it could not be found anymore;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said sim card and thereafter requesting replacement of the
same.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2023, at
Dipolog City.

GINYMFA S. ENTRINA
(Affiant)
Drivers License#J07-20-005982
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at Dipolog City.

Doc. No.

Page No.

Book No.

Series of 2023
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, MARIA MARIE BITONG CUENCA, of legal age, Filipino, single, a resident of

Purok Malayan 1, Sta. Filomena, Dipolog City, Zamboanga del Norte after
having been duly sworn in accordance with law, hereby depose and state:

That I was a holder and possessor of a Philippine Passport issued by the

Department of Foreign Affairs;

That on July 10, 2023 I discovered that my passport was lost;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
passport.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2023, at Dipolog City.

MARIA MARIE BITONG CUENCA

(Affiant)
Voters ID#7202-0226B-A1296MBC20000-0
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at

Dipolog City.

Doc. No.___

Page No.___

Book No.___

Series of 2023
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I:JERRY LORIJO BUAGAS, of legal age, Filipino, single, a resident of Galas,

Dipolog City, Zamboanga del Norte after having been duly sworn in
accordance with law, hereby depose and state:

That I was a holder and possessor of Original Copy of Certificate of

Registration(CR) with Engine No.4PF-120489, Chassis No.4PF-120489, Plate
No.JY-5107 issued by the Land Transportation Office(LTO);

That recently, I discovered that the said original copy of CR was lost;

That despite effort to recover the same but it was naught. Hence, we
considered it as totally lost.

As such, we are executing this Affidavit of Loss to attest to the truth of the
foregoing statements and for the purpose of attesting to the loss of the said
original copy of CR.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2023, at Dipolog City.

JERRY L. BUAGAS
(Affiant)
Drivers License#J01-17-003809
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at

Dipolog City showing her document of identification as indicated above.

Doc. No.

Page No.

Book No.

Series of 2023
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, TEODORVINE S. EVARDO, of legal age, Filipino,widow resident of Central Barangaay, Dipolog City,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am the holder and possessor of receipts issued by BIR on transaction of tax payments on parcels of land
known as 1.) Lot 171-G, Psd-09-000285, situated at Patunan, Manukan, Zamboanga del Norte, and covered by
Transfer Certificate of Title No.T-86508, containing an area of 3,827 square meters and 2.) A parcel of land
known Lot 171-A, Psd-09-000285, situated at Patunan, Manukan, Zamboanga del Norte,
and covered by Transfer Certificate of Title No.T-86507, containing an area of 12,058
square meters.

That I have lost the said receipts;

That despite effort to recover the same but it was naught.

That I/he considered it as totally lost.

That I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for the purpose
of attesting to the loss of the said BIR receipts.

IN WITNESS WHEREOF, I have hereunto affixed my signature this __th day of _______ 2023, at Dipolog
City.

TEODORVINE S. EVARDO

(Affiant)

Valid ID#__________

SUBSCRIBED AND SWORN to before me this ___th day of ________ 2023, at Dipolog City.

DOC.NO. ______

PAGE NO.___

BOOK NO.___

SERIES OF 2023
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, CRISANTO S. ENOY, of legal age, Filipino, married, and with address of

Sicayab, Dipolog City, Zamboanga del Norte after having been duly sworn in
accordance with law, hereby depose and state:

That I was a holder and possessor of duplicate copy of e-Certificate Authorizing

Registration(eCAR) for the taxes on the purchased property covered by TCT No.T-
57554 located at Manukan, ZN which were paid in the Bureau of Internal Revenue
RDO 91. That the eCAR was numbered eCR201800001671;

That recently I discovered that my said documents were lost;

That despite effort to recover the same but it was naught. Hence, I considered it
as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
statements and for the purpose of attesting to the loss of the said documents.
IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of
__________ 2023, at Dipolog City. massive

CRISANTO S. ENOY
(Affiant)
Valid ID#_______________________

With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at Dipolog
City showing his/her document of identity as indicated above.

Doc. No.___

Page No.___

Book No.___

Series of 2023

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, JENEVE MUNDOY FERRAREN-RAZAGA, of legal age, Filipino, married, a

resident of Purok Kamunggay, Baybay, Galas, Dipolog City, Zamboanga del
Norte after having been duly sworn in accordance with law, hereby depose
and state:

That I was a holder and possessor of a Philippine Passport issued by the

Department of Foreign Affairs;

That recently I discovered that my passport was lost;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.
As such, I am executing this Affidavit of Loss to attest to the truth of the
foregoing statements and for the purpose of attesting to the loss of the said
passport.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2023, at Dipolog City.

JENEVE MUNDOY FERRAREN-RAZAGA

(Affiant)
TIN#380-847-581
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at

Dipolog City.

Doc. No.___

Page No.___

Book No.___

Series of 2023

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I:PAUL NUARY JAN GAYLANAN ESPINOSA, of legal age, Filipino, single, a

resident of Purok 3, Dicayas,Dipolog City, Zamboanga del Norte after
having been duly sworn in accordance with law, hereby depose and state:

That I was a holder and possessor of Drivers License and its Original Copy of
Official Receipt(OR) issued by the Land Transportation Office(LTO);

That recently, I discovered that the said drivers license and its original copy
of OR was lost;
That despite effort to recover the same but it was naught. Hence, we
considered it as totally lost.

As such, we are executing this Affidavit of Loss to attest to the truth of the
foregoing statements and for the purpose of attesting to the loss of the said
drivers license and original copy of OR.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2023, at Dipolog City.

PAUL NUARY JAN G. ESPINOSA

(Affiant)
Valid ID#________
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at

Dipolog City showing her document of identification as indicated above.

Doc. No.

Page No.

Book No.

Series of 2023
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, CRISANTO S. ENOY, of legal age, Filipino, married, and with address of

Sicayab, Dipolog City, Zamboanga del Norte after having been duly sworn in
accordance with law, hereby depose and state:

That I was a holder and possessor of duplicate copy of e-Certificate Authorizing

Registration(eCAR) for the taxes on the purchased property covered by TCT No.T-
57554 located at Manukan, ZN which were paid in the Bureau of Internal Revenue
RDO 91. That the eCAR was numbered eCR201800001671;

That recently I discovered that my said documents were lost;

That despite effort to recover the same but it was naught. Hence, I considered it
as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
statements and for the purpose of attesting to the loss of the said documents.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2023, at Dipolog City. massive

CRISANTO S. ENOY
(Affiant)
Valid ID#_______________________

With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at Dipolog
City showing his/her document of identity as indicated above.

Doc. No.___

Page No.___

Book No.___

Series of 2023
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, TEODORVINE S. EVARDO, of legal age, Filipino,widow resident of Central Barangaay, Dipolog City,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am the holder and possessor of claim slip issued by BIR for the donation I made to my child which a
land known as Lot 171-G, Psd-09-000285, situated at Patunan, Manukan, Zamboanga del Norte, and covered
by Transfer Certificate of Title No.T-86508, containing an area of 3,827 square meters

That my principal had lost the said slip;

That despite effort to recover the same but it was naught.

That I/he considered it as totally lost.

That I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for the purpose
of attesting to the loss of the said BIR Claim slip.

IN WITNESS WHEREOF, I have hereunto affixed my signature this __th day of _______ 2023, at Dipolog
City.

TEODORVINE S. EVARDO

(Affiant)

Valid ID#__________

SUBSCRIBED AND SWORN to before me this ___th day of ________ 2023, at Dipolog City.

DOC.NO. ______

PAGE NO.___

BOOK NO.___

SERIES OF 2023
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, JAZZ LEGADOS VILLAVICENCIO, of legal age, Filipino, single, a resident of Gonzales St., Cor.Lopez
Jaena St., Baisong, Dipolog City, Zamboanga del Norte after having been duly sworn in accordance
with law, hereby depose and state:

That I was holder and possessor of a Professional Regulation Commission(PRC) Identification(ID) card
as Registered Nurse and my Philhealth ID card. Both of them was contained inside my wallet;

That I discovered that my wallet containing PRC license and Philhealth ID was lost, and could not be
found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said PRC license and Philhealth ID.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2023, at
Dipolog City.

JAZZ LEGADOS VILLAVICENCIO

(Affiant)
Philippine ID#5106-8034-9827
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at Dipolog City.

Doc. No.

Page No.

Book No.

Series of 2023
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, REX V. VALMORIA, of legal age, Filipino,single, a resident of Gulayon, Dipolog

City, Zamboanga del Norte after having been duly sworn in accordance with law,
hereby depose and state:

That I was a holder and possessor of a sepia copy, and other copies of blueprint of
Approved Subdivision Plan PSD-09-046459 for parcel of land covered by OCT
No.P-847, situated at Gulayon, DIpolog City, Zamboanga del Norte.

That recently while I was checking my file containing the said documents so that I
could process titling over said land, I found out that the documents were lost, and
could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it
as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
statements and for the purpose of attesting to the loss of the said sepia copy, and
technical descriptions documents and request for replacement of the same.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2023, at Dipolog City.

REX V. VALMORIA
(Affiant)

ID#D4695345

With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at Dipolog
City.

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, SYRENE RENIGADO SYGACO, of legal age, Filipino, single, a resident of

Bolicon,Turno, Dipolog City, Zamboanga del Norte after having been duly
sworn in accordance with law, hereby depose and state:

That I was a holder and possessor of a Philippine Passport issued by the

Department of Foreign Affairs;

That on August 14, 2023, I was riding a passenger tricycle from Philippine
Statistics Authority in Dipolog City bringing my said passport. That upon
arrival at destination, the undersigned discovered that the said passport
was lost. That I believed it was lost at the tricycle;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
passport.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2023, at Dipolog City.

SYRENE R. SYGACO
(Affiant)
Philippine ID#6295-3748-7924-6017n
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at

Dipolog City.

Doc. No.___

Page No.___

Book No.___

Series of 2023
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I:REMOND MAYLON DAGPIN, of legal age, Filipino, married, a resident of

Gulayon, Dipolog City after having been duly sworn in accordance with law,
hereby depose and state:

That I was a holder and possessor of Certificate of Registration or BIR Form

No.2303 registered under the name of my wife Cathlea Hermoso Dagpin
and some of BIR related documents like receipts;

That the said documents were soaked by water after the adjacent building
where we kept our paper was caught with fire. That after I dried those
documents we lost it;

That despite effort to recover the same but it was naught. Hence, we
considered it as totally lost.

As such, we are executing this Affidavit of Loss to attest to the truth of the
foregoing statements and for the purpose of attesting to the loss of the said
Certificate of Registration or BIR Form No.2303 and some of BIR related
documents.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2023, at Dipolog City.

REMOND MAYLON DAGPIN

(Affiant)
Drivers License#G06-13-002924
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at

Dipolog City showing her document of identification as indicated above.

Doc. No.

Page No.

Book No.

Series of 2023
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I:MA. GINALYN OMBIANG MANDIAG, of legal age, Filipino, married, a resident

of Purok Bangus, North Baybay, Galas,Dipolog City, Zamboanga del Norte
after having been duly sworn in accordance with law, hereby depose and
state:

That I was a holder and possessor of Philhealth ID issued by Philhealth,

National ID issued by PSA, Cebuana Lhuillier receipt issued by Cebuana
Lhuillier for pawned jewelry and M Lhuillier receipt issued by MLhuillier for
pawned jewelries;

That on August 5, 2023 I discovered those documents were taken from our
store and were lost;

That despite effort to recover the same but it was naught. Hence, we
considered it as totally lost.

As such, we are executing this Affidavit of Loss to attest to the truth of the
foregoing statements and for the purpose of attesting to the loss of the said
Philhealth ID issued by Philhealth, National ID issued by PSA, Cebuana
Lhuillier receipt issued by Cebuana Lhuillier for pawned jewelry and M
Lhuillier receipt issued by MLhuillier for pawned jewelries.
IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of
__________ 2023, at Dipolog City.

GINALYN OMBIANG MANDIAG

(Affiant)
Valid ID#___________________
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at

Dipolog City showing her document of identification as indicated above.

Doc. No.

Page No.

Book No.

Series of 2023

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I:CRISTOPHER RUIZ CAǸETE, of legal age, Filipino, single, a resident of Purok

Pangadlaw, Turno,Dipolog City, Zamboanga del Norte after having been
duly sworn in accordance with law, hereby depose and state:

That I was a holder and possessor of Drivers License and its Original Copy of
Official Receipt(OR) issued by the Land Transportation Office(LTO);

That recently, I discovered that the said drivers license and its original copy
of OR was lost;

That despite effort to recover the same but it was naught. Hence, we
considered it as totally lost.
As such, we are executing this Affidavit of Loss to attest to the truth of the
foregoing statements and for the purpose of attesting to the loss of the said
drivers license and original copy of OR.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2023, at Dipolog City.

CRISTOPHER R. CAǸETE
(Affiant)
DL#J01-16001301
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at

Dipolog City showing her document of identification as indicated above.

Doc. No.

Page No.

Book No.

Series of 2023

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, GERLY ALARCON VILLONES, of legal age, Filipino, married, a resident of Purok Orchids, Gulayon,
Dipolog City, Zamboanga del Norte after having been duly sworn in accordance with law, hereby
depose and state:

That I am mother of minor Glaiza A. Villones, a Grade VI pupil of Gulayon Integrated School, located at
Gulayon, Dipolog City
That my said child was a holder and possessor of a textbook issued by school with title Joy in Learning
Textbook;

That the said textbook was lost;

That despite effort to recover the same but it was naught. Hence, she considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said textbook.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2023, at
Dipolog City.

GERLY ALARCON VILLONES

(Affiant)
VIN#7202-0176B-C1280GAV20000-5
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023 by above-named person
showing her document of identity as shown above, at Dipolog City.

Doc. No.

Page No.

Book No.

Series of 2023
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, BERNARD JUNE BELONG IBANGA, of legal age, Filipino, married, a resident of Ubay, Pi ǹan,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I was a holder and possessor of a TM Sim card with number 639530887404;

That recently, I discovered that my said simcard was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said sim card and thereafter requesting replacement of the
same.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2023, at
Dipolog City.

BERNARD JUN BELONG IBANGA

(Affiant)
Driver’s License#J01-19-007756
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023 by above-named person
showing her document of identity as shown above, at Dipolog City.

Doc. No.

Page No.

Book No.

Series of 2023
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ELIZABETH O. CUDAL, of legal age, Filipino, widow, and with address of

Estaka, Dipolog City, Zamboanga del Norte after having been duly sworn in
accordance with law, hereby depose and state:

That I was a holder and possessor of duplicate copy of e-Certificate Authorizing

Registration(eCAR) for the taxes on the estates of my late mother Dominga P.
Ortega which were paid in the Bureau of Internal Revenue RDO 91;

That recently I discovered that my said documents were lost;

That despite effort to recover the same but it was naught. Hence, I considered it
as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
statements and for the purpose of attesting to the loss of the said documents.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2023, at Dipolog City. massive

ELIZABETH O. CUDAL
(Affiant)
OSCA ID#14323-Dipolog City

With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at Dipolog
City showing his/her document of identity as indicated above.

Doc. No.___

Page No.___

Book No.___

Series of 2023
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, WINCESLAO B. TIMONAN,JR, of legal age, Filipino, married, a resident of

Baybay, Galas, Dipolog City, Zamboanga del Norte, after having been duly
sworn in accordance with law, hereby depose and state:

That I was a holder and possessor of an AFPSLAI Red Passbook issued by

AFPSLAI;
That recently, while I was trying to look for the said AFPSLAI Passbook from
where I kept it, I found out that the AFPSLAI Passbook was lost, and could
not be found;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost;

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

foregoing statements and for the purpose of attesting to the loss of the said
AFPSLAI Red Passbook.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2023, at Dipolog City.

WINCESLAO B. TIMONAN,JR.
(Affiant)
Philhealth ID#14-000074405-7
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at

Dipolog City showing his/her document of identity as indicated above.

Doc No. _____

Page No. _____
Book No. ____
Series of 2023

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS
I:ARVIR E. AGECIA, of legal age, Filipino, married, a resident of Dipolog City,
Zamboanga del Norte after having been duly sworn in accordance with law,
hereby depose and state:

That I was a holder and possessor of Drivers License and its Original Copy of
Official Receipt(OR) issued by the Land Transportation Office(LTO);

That recently, I discovered that the said drivers license and its original copy
of OR was lost;

That despite effort to recover the same but it was naught. Hence, we
considered it as totally lost.

As such, we are executing this Affidavit of Loss to attest to the truth of the
foregoing statements and for the purpose of attesting to the loss of the said
drivers license and original copy of OR.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2023, at Dipolog City.

ARVIR E. AGECIA
(Affiant)
SSS ID#33-6770280-2
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at

Dipolog City showing her document of identification as indicated above.

Doc. No.

Page No.

Book No.

Series of 2023

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x
 AFFIDAVIT OF LOSS

I, FLORIDA DAHONOS TOLIN, of legal age, Filipino, single, and with address of
Blk 31, Lot 8, Victoria Country Homes, Obay, Polanco, Zamboanga del Norte after
having been duly sworn in accordance with law, hereby depose and state:

That I was a holder and possessor of duplicate copy of e-Certificate Authorizing

Registration(eCAR) with its edge had blue color color for taxes paid on sale of
building and parcel of land known as Lot 8, Block 31, Pcs-097210-001313 located
at Obay, Polanco, Zamboanga del Norte covered by TCT No.T-55639 in favor of
Rodvic Angelo U Miranda and Nico Edrei U. Miranda, issued by the BIR. That all
related documents on the said conveyance were turned over to me by the seller
Mirandas;

That recently I discovered that my said documents were lost;

That despite effort to recover the same but it was naught. Hence, I considered it
as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
statements and for the purpose of attesting to the loss of the said documents.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2023, at Dipolog City. massive

FLORIDA DAHONOS TOLIN

(Affiant)
Phil.Passport#P9133424A

With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at Dipolog
City showing his/her document of identity as indicated above.

Doc. No.___

Page No.___

Book No.___/

Series of 2023

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS
I:ANA MAE LACAYA, of legal age, Filipino, single, a resident of Anastacio,
Polanco, Zamboanga del Norte after having been duly sworn in accordance
with law, hereby depose and state:

That I was a holder and possessor of Original Copy of Certificate of

Registration(CR) with No.0908-000000070132 for motor vehicle with details
Motor No.:E31TE-0109689, Chassis No.:PA0SEF210J0109781,CR
No.335233710 issued by the Land Transportation Office(LTO);

That recently, I discovered that the said original copy of CR was lost;

That despite effort to recover the same but it was naught. Hence, we
considered it as totally lost.

As such, we are executing this Affidavit of Loss to attest to the truth of the
foregoing statements and for the purpose of attesting to the loss of the said
original copy of CR.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2023, at Dipolog City.

ANA MAE LACAYA

(Affiant)
Valid ID#_____________
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at

Dipolog City showing her document of identification as indicated above.

Doc. No.

Page No.

Book No.

Series of 2023
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, CONCEPCION PARTOSA DUTERTE, of legal age, Filipino,married, a resident

of Blk 33, Lot 9, VCH, Obay, Polanco, Zamboanga del Norte after having
been duly sworn in accordance with law, hereby depose and state:

That I was a holder and possessor of Unified Multipurpose

Identification(UMID) Card with car number CRN-006-004-276096 issued by
the Government Service Insurance System(GSIS);

That recently I discovered that my UMID was lost;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
UMID.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2023, at Dipolog City.

CONCEPCION PARTOSA DUTERTE

(Affiant)
PRC ID#0474157
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at

Dipolog City.

Doc. No.___

Page No.___

Book No.___

Series of 2023
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, MARYBETH A. ANDILAB, of legal age, Filipino, married, a resident of

Poblacion, Sibutad, Zamboanga del Norte after having been duly sworn in
accordance with law, hereby depose and state:

That I am Barangay Treasurer of Barangay Poblacion, Sibutad, Zamboanga

del Norte;

That I am processing the titling over a parcel of land and two of the
documents were the ROR/OR Nos. 00612886 and 00612885 as payments
for Capital Gains Tax and Documentary Stamp Tax over parcel of land
purchased covered by Katibayan ng Orihinal na Titulo Blg.P-48986 located
at Sibutad, Zamboanga del Norte.

That recently I discovered that the said ROR/OR were lost, and could not be
found;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost;

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

foregoing statements and for the purpose of attesting to the loss of the said
ROR/OR.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2023, at Dipolog City.

MARYBETH A. ANDILAB

(Affiant)

DILG ID#090123012-11

With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at

Dipolog City.
Doc. No.

Page No.

Book No.

Series of 2023

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I:DAISY I. SALVADOR, of legal age, Filipino , married, a resident of Bandera,

Polanco, Zamboanga del Norte after having been duly sworn in accordance
with law, hereby depose and state:

That I was a holder and possessor of a driver’s license and official receipt
issued by the Land Transportation Office(LTO);

That the file containing the said drivers license with receipt was lost;

That despite effort to recover the same but it was naught. Hence, we
considered it as totally lost.

As such, we are executing this Affidavit of Loss to attest to the truth of the
foregoing statements and for the purpose of attesting to the loss of the said
driver’s license with 4receipt.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2023, at Dipolog City.

DAISY I. SALVADOR
(Affiant)
Valid ID#_________________________
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at

Dipolog City.

Doc. No.

Page No.
Book No.

Series of 2023

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT

I, NANCY L. KWAN-VALENCIA, of legal age, Filipino, married, a resident of Miputak, Dipolog City,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am the registered owner of a motor vehicle, with following details:

Make: Toyota CR No.:45034173-2

Plate No.:KAO3392 Engine No.:2GDC990086

Chassis No.:MR0JB8DD1N3189792

That the said motor vehicle is owned by the Mias Lumber Enterprises with business address at Dr.
Rizal, Katipunan, Zamboanga del Norte;

That the possession of the said motor vehicle was initially with the company however upon
employment of my brother ROBERT L. KWAN sometime in June 2022 the said motor vehicle was
assigned to him by the company for business operation-related purposes;

That then on May 25, 2023, ROBERT L. KWAN left from the company he also brought with the said
motor vehicle without consent or authority from the company;

That ROBERT L. KWAN has still possession and enjoyment over the said motor vehicle until present
and the undersigned and the company do not have the possession and control over it;

That I hereby state any infractions committed by ROBERT L. KWAN using the said motor vehicle has no
relations or authority from the undersigned or the company;

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

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2023, at
Dipolog City.

NANCY L. KWAN-VALENCIA
(Affiant)
PRC ID#0091395-valid until 09/29/2023
 With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at Dipolog City showing her
document of identity as indicated above.

Doc. No.

Page No.

Book No.

Series of 2023

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, LUZMINDA B. KIBRAJOSA, of legal age, Filipino, widow, a resident of Turno, Dipolog City, Zamboanga
del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I was holder and possessor of an AFPSLAI identification(ID) card of my late spouse DOUGLAS
LAGRIMAS KIBRAJOSA;

That recently I discovered that the said AFPSLAI ID was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said ID.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2023, at
Dipolog City.
 LUZMINDA B. KIBRAJOSA
(Affiant)
OSCA ID#6780-Dipolog City
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at Dipolog City.

Doc. No.

Page No.

Book No.

Series of 2023

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, SHEBA CATAYLO RONQUILLO, of legal age, Filipino, married, a resident of Galas, Dipolog City,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a high school graduate at Galas National High School, with address at Galas, Dipolog City;

That I was holder and possessor of a Diploma as a graduate of said school;

That recently I discovered that the original copy of my Diploma was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said document.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2023, at
Dipolog City.

SHEBA CATAYLO RONQUILLO

(Affiant)
Philhealth ID#14-050116534-0
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at Dipolog City.

Doc. No.

Page No.

Book No.

Series of 2023
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I:DAISY MAE B. DUNQUE, of legal age, Filipino, married, a resident of

Gulayon, Dipolog City, Zamboanga del Norte after having been duly sworn
in accordance with law, hereby depose and state:

That I am the Manager of Dale’s Minimart and also the Manager of Family
Pharmacy, both with business address of Gulayon, Dipolog City;

That I am the safekeeper and possessor the sales invoice of the said
businesses;

That recently, I discovered that the stub of sales invoice of Family Pharmacy
with serial numbers 3401 until 3450, and another stub of sales invoice with
serial number 3051 until 3100 ;

That despite effort to recover the same but it was naught. Hence, we
considered it as totally lost.

As such, we are executing this Affidavit of Loss to attest to the truth of the
foregoing statements and for the purpose of attesting to the loss of the said
sales invoices.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2023, at Dipolog City.

DAISY MAE B. DUNQUE

(Affiant)
Philhealth ID#14-175209652-2
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at

Dipolog City.

Doc. No.

Page No.

Book No.

Series of 2023
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I:MARTIN I. BANAGUA, of legal age, Filipino , a resident of Malvar St. Ext.,

Dipolog City, Zamboanga del Norte after having been duly sworn in
accordance with law, hereby depose and state:

That I was a holder and possessor of official receipt issued by the Land
Transportation Office(LTO) for the renewal of registration of motor vehicle
with Plate No.JN2767;

That the file containing the said receipt was lost;

That despite effort to recover the same but it was naught. Hence, we
considered it as totally lost.

As such, we are executing this Affidavit of Loss to attest to the truth of the
foregoing statements and for the purpose of attesting to the loss of the said
receipt.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2023, at Dipolog City.

MARTIN I. BANAGUA
(Affiant)
Valid ID#_________________________
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at

Dipolog City.

Doc. No.

Page No.

Book No.

Series of 2023
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, JACHELENE RUEDAS-RUEDAS, of legal age, Filipino, married, a resident of Barra, Dipolog City,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I was holder and possessor of an original copy of original copy of Cancellation of Real Estate
Mortgage issued by the Metrobank over a parcel of land covered by Transfer Certificate of Title No.T-
20537 issued by the Register of Deeds for Dipolog City;

That recently I discovered that the original copy of said cancellation of mortgage document was lost,
and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said document.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2023, at
Dipolog City.

JACHELENE RUEDAS RUEDAS

(Affiant)
Driver’s License#J01-93-015817 valid until 2032/04/27
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at Dipolog City showing
his/her document of identity as indicated above.

Doc. No.

Page No.

Book No.

Series of 2023
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, CRIS FRANCIS V. BELUAN, of legal age, Filipino, a resident of Gulayon, Dipolog City, Zamboanga del
Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a graduate at Saint Vincent’s College, Inc.-Dipolog City;

That I was holder and possessor of a Diploma as a graduate of said school;

That recently I discovered that the original copy of my Diploma was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said document.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2023, at
Dipolog City.

CRIS FRANCIS V. BELUAN

(Affiant)
Driver’s License#J01-06-003368 valid until 2024/09/06
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at Dipolog City.

Doc. No.

Page No.

Book No.
Series of 2023

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF COMPLETE ADDRESS

I:JERRY PACLAR MUNION, of legal age, Filipino, married, a resident of Block

42, Lot 5, Victoria Country Homes, Obay, Polanco, Zamboanga del Norte
after having been duly sworn in accordance with law, hereby depose and
state:

That I am attesting that my complete address is Block 42, Lot 5, Victoria

Country Homes, Obay, Polanco, Zamboanga del Norte , Philippines;

That I am attesting the truthfulness of the foregoing statements and for

other legal purposes as may be required.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2023, at Dipolog City.

JERRY PACLAR MUNION

(Affiant)
Driver’s License#K12-98-007610
 With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at

Dipolog City showing his/her document of identity as shown above.

Doc. No.

Page No.

Book No.

Series of 2023

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I:EDWARD R. ALCANTARA, of legal age, Filipino, single, a resident of 9 L 18

Pacita Complex San Vicente, Laguna after having been duly sworn in
accordance with law, hereby depose and state:

That I am a driver of a delivery and I was issued by the Highway Patrol

Group(HPG)-of the PNP with an TOP with number 000000019097970 for the
vehicle’s plate number’s impoundment in Masbate City sometime year
2018;

That I recently discovered that the TOP receipt was lost;

That despite effort to recover the same but it was naught. Hence, we
considered it as totally lost.

As such, we are executing this Affidavit of Loss to attest to the truth of the
foregoing statements and for the purpose of attesting to the loss of the said
receipt.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2023, at Dipolog City.

EDWARD R. ALCANTARA
 (Affiant)
Driver’s License#D04-15-012285
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at

Dipolog City.

Doc. No.

Page No.

Book No.

Series of 2023

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I:MIKE A. VALLECER, of legal age, Filipino, single, a resident of San Antonio,

Manukan, Zamboanga del Norte after having been duly sworn in
accordance with law, hereby depose and state:

That I was a holder and possessor of Driver’s License and its official receipt
issued by the Land Transportation Office(LTO);

That my wallet containing the said Driver’s License card and receipt was
lost;

That despite effort to recover the same but it was naught. Hence, we
considered it as totally lost.

As such, we are executing this Affidavit of Loss to attest to the truth of the
foregoing statements and for the purpose of attesting to the loss of the said
Driver’s License card and its receipt.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2023, at Dipolog City.

MIKE A. VALLECER
(Affiant)
Valid ID#_________________________
With photo
SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at
Dipolog City.

Doc. No.

Page No.

Book No.

Series of 2023

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, JESSIE PAGONG ACOJEDO, of legal age, Filipino, married, a resident of Owaon, Dapitan City,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of an Automated Teller Machine(ATM) card issued by Land Bank of
the Philippines(LBP) Dipolog City Branch .

That recently, I discovered that the LBP ATM card was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said LBP ATM card and thereafter requesting replacement
thereon.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2023, at
Dipolog City.

JESSIE PAGONG ACOJEDO

(Affiant)
Driver’s License#J01-10-002630
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2023
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ELVIRA O. ALEJO, of legal age, Filipino, married to Leopoldo G. Alejo, resident of Sicayab, Dipolog City,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am one of the heirs of late Spouses Anecita Ybanez and Fidel Orong, registered owner of a parcel of
land, more particularly described as follows:

A parcel of land known as Lot No.2555-B-2-F, Psd-09-016929, covered by Transfer Certificate of Title No.T-
9035 situated at Sicayab, Dipolog City, Zamboanga del Norte, containing an area of 7,254 square meters issued
by the Register of Deeds for Dipolog City.

That I am the only surviving child of my parents;

That the owner’s copy of said parcel of land’s title was turned over to me and after lapse of time I forgot where
I kept it;

That despite effort to recover the same but it was naught.

That I considered it as totally lost.

That I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for the purpose
of attesting to the loss of the said owner’s copy of Transfer Certificate of Title No.T-9035.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ____th day of _____________ 2023, at
Dipolog City.

ELVIRA O. ALEJO
(Affiant)
PRC ID#061047
With photo

SUBSCRIBED AND SWORN to before me this ___th day of _________ 2023, at Dipolog City showing the
document of identity as shown above.

DOC.NO. ______

PAGE NO.___

BOOK NO.___
SERIES OF 2023

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, SALOME B. SINAY, of legal age, Filipino, married, a resident of Magangon,Polanco, Zamboanga del
Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of a Smart Sim card with number 639515381183;

That recently, I discovered that my said simcard together with cellphone was lost, and could not be
found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said sim card and thereafter requesting replacement of the
same.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2023, at
Dipolog City.

SALOME B. SINAY
(Affiant)
Voters ID#7210-0060B-G0870SBS20000
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023 by above-named person
showing her document of identity as shown above, at Dipolog City.

Doc. No

Page No

Book No

Series of 2023
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ANGELOU C. GORNEZ, of legal age, Filipino, single/married, a resident of Polanco, Zamboanga del
Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of a Globe Sim card with number 639771250087;

That recently, I discovered that my said simcard together with cellphone was lost, and could not be
found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said sim card and thereafter requesting replacement of the
same.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2023, at
Dipolog City.

ANGELOU C. GORNEZ
(Affiant)
Philhealth ID#03-026088046-9
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023 by above-named person
showing her document of identity as shown above, at Dipolog City.

Doc. No

Page No

Book No

Series of 2023
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, KATHEA LOU O. ZAMORAS, of legal age, Filipino, single, a resident of

Gulayon, Dipolog City, Zamboanga del Norte after having been duly sworn
in accordance with law, hereby depose and state:

That I was a holder and possessor of a Rural Bank of Rizal(RBR) Passbook

with account number 005-001-2905 issued by RBR-Polanco, Zamboanga del
Norte Branch;

That on June 20, 2023, I found out that my RBR Passbook was lost;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
Passbook.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2023, at Dipolog City.

KATHEA LOU O. ZAMORAS

(Affiant)
PRC ID#0730744 valid until 11/15/2023s
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at

Dipolog City.

Doc. No.___

Page No.___

Book No.___

Series of 2023
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, FRENCITO G. PASIGNA, of legal age, Filipino, single/married, resident of Obay, Polanco, Zamboanga del
Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am the representative of Gaudioso Dagpin and Concepcion Dagpin, registered owner of a parcel of land,
more particularly described as follows:

A parcel of land known as Lot No.3093-B, Psd-09-074743, covered by Transfer Certificate of Title No.127-
2023000977 situated at Poblacion,Polanco, Zamboanga del Norte, containing an area of 250 square meters
issued by the Register of Deeds for Zamboanga del NOrte.

That I processed the titling over the said parcel of land and the owner’s copy was turned over to me by Mr.
Dagpin, however after I initiated the process I suddenly forgot where I kept or left it;

That despite effort to recover the same but it was naught.

That I considered it as totally lost.

That I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for the purpose
of attesting to the loss of the said owner’s copy of Transfer Certificate of Title No.127-2023000977.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ____th day of _____________ 2023, at
Dipolog City.

FRENCITO G. PASIGNA
(Affiant)
OSCA ID#18-03592, Polanco,ZN
With photo

SUBSCRIBED AND SWORN to before me this ___th day of _________ 2023, at Dipolog City.

DOC.NO. ______

PAGE NO.___

BOOK NO.___

SERIES OF 2023
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, LOREVIT B. NOEL, of legal age, Filipino,single/married, with office address

of Real Motors, Katipunan, Zamboanga del Norte after having been duly
sworn in accordance with law, hereby depose and state:

That I was a holder and possessor of a Sales Invoice with number KAP-
019741 issued by Real Motors-Katipunan, Zamboanga del Norte Branch;

That the said sales invoice was lost;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
sales invoice.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2023, at Dipolog City.

LOREVIT B. NOEL
(Affiant)
Valid ID#____________
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at

Dipolog City.

Doc. No.___

Page No.___

Book No.___

Series of 2023
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ERNESTO TAN GONZALES, of legal age, Filipino,married, a resident of 243

Gomez St, Dipolog City, Zamboanga del Norte after having been duly sworn
in accordance with law, hereby depose and state:

That I was a holder and possessor of a Community Rural Bank of Dapitan ,

Inc.(CRBDI) Passbook issued by CRBDI-Dipolog City Branch;

That recently, I found out that my CRBDI Passbook was lost;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
Passbook.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2023, at Dipolog City.

ERNESTO TAN GONZALES

(Affiant)
Driver’s License#J01-90-011528
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at

Dipolog City.

Doc. No.___

Page No.___
Book No.___

Series of 2023

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, RANULFO F. ALUMBRE of legal age, Filipino, married, a resident of Sta.Filomena, Dipolog

City, Zamboanga del Norte after having been duly sworn in accordance with law, hereby
depose and state:

That I was a possessor and holder of Senior citizen’s identification card issued by the Office of
the Senior Citizen’s Affairs(OSCA).

That recently my said Senior citizen’s identification card was lost;

That despite effort to recover the same but it was naught.

Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements
and for the purpose of attesting to the loss of the said Senior citizen’s identification card.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2023,
at Dipolog City.

RANULFO F. ALUMBRE

(Affiant)

Voters ID#7202-0223B-E2453RFA10000-7

SUBSCRIBED AND SWORN to before me showing his/her document of identification as shown

above this ___ day of _________ 2023, at Dipolog City.

Doc. No

Page No
Book No

Series of 2023

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, EULALIA O. ALUMBRE of legal age, Filipino, married, a resident of Sta.Filomena, Dipolog City,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose
and state:

That I was a possessor and holder of a Pantawid Pamilyang Pilipino Program(4Ps) cash card of
Department of Social Welfare and Development(DSWD) with card number
6031210005100482044 issued by Land Bank of the Philippines.

That recently my said cash card was lost;

That despite effort to recover the same but it was naught.

Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements
and for the purpose of attesting to the loss of the said 4Ps cash card.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2023,
at Dipolog City.

EULALIA O. ALUMBRE

(Affiant)

OSCA ID#11907-Dipolog City

SUBSCRIBED AND SWORN to before me showing his/her document of identification as shown

above this ___ day of _________ 2023, at Dipolog City.

Doc. No

Page No
Book No

Series of 2023

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ROEL B. DIHAYCO, of legal age, Filipino, married , with office address of DCIT, National Highway,
Minaog, Dipolog City, Zamboanga del Norte after having been duly sworn in accordance with law,
hereby depose and state:

That I am the TESDA Coordinator of Dipolog City Institute of Technology, Inc.(DCIT) with address of
Minaog, Dipolog City;
That recently, I was looking for the original copy of Certificate of TVET Program Registration with
number WTR No.20220972ELCEIM215047 issued by Technical Education and Skills Development
Authority(TESDA) to DCIT however I could not found the original copy;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said Certificate of TVET Program Registration with number
WTR No.20220972ELCEIM215047 and thereafter requesting replacement of the same.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2023, at
Dipolog City.

ROEL B. DIHAYCO
(Affiant)
Philippine ID#4961-9086-7460-3629
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023 by above-named person
showing his/her document of identity as shown above, at Dipolog City.

Doc. No

Page No

Book No

Series of 2023

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ROSSE RIC P. VELASCO, of legal age, Filipino, single, a resident of Lapu-lapu St., Estaka, Dipolog City,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of a Talk’n Text Sim card with number 09106252108;

That recently, I discovered that my said simcard together with cellphone was lost, and could not be
found;
That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said sim card and thereafter requesting replacement of the
same.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2023, at
Dipolog City.

ROSSE RIC P. VELASCO

(Affiant)
Driver’s License#J01-15-003062
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023 by above-named person
showing her document of identity as shown above, at Dipolog City.

Doc. No

Page No

Book No

Series of 2023

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, RONALD DIPAS DAYDAY, Filipino, of legal age, single, and a resident of

Turno, Dipolog City, Zamboanga del Norte after having been duly sworn in
accordance with law, hereby depose and state:

That I am a holder and possessor of receipt issued by Cebuana Lhuillier-

Dipolog City Branch 4 for pawned jewelry which is a ring;

That recently, my receipt was lost due to fire;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
receipt.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2023, at Dipolog City.

RONALD DIPAS DAYDAY

(Affiant)
Philippine ID#3579-1026-9041-7094
With phot

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at

Dipolog City.

Doc. No.__
Page No.__
Book No.__
Series of 2023

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ROEL I. BAGWASAN of legal age, Filipino, single/married, a resident of Isis,Polanco,

Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose
and state:

That I was a possessor and holder of a Pantawid Pamilyang Pilipino Program(4Ps) cash card of
Department of Social Welfare and Development(DSWD) issued by Land Bank of the
Philippines.

That recently my said cash card was lost;

That despite effort to recover the same but it was naught.

Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements
and for the purpose of attesting to the loss of the said 4Ps cash card.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2023,
at Dipolog City.

ROEL I. BAGWASAN

(Affiant)

Valid ID#______________

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at Dipolog City.
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I:MARK JOSEPH P. CHIPOCO, of legal age, Filipino, single, a resident of Seres,

Katipunan, Zamboanga del Norte after having been duly sworn in
accordance with law, hereby depose and state:

That I was a holder and possessor of Driver’s License and its official receipt
issued by the Land Transportation Office(LTO);

That my wallet containing the said Driver’s License card and receipt was
lost;

That despite effort to recover the same but it was naught. Hence, we
considered it as totally lost.

As such, we are executing this Affidavit of Loss to attest to the truth of the
foregoing statements and for the purpose of attesting to the loss of the said
Driver’s License card and its receipt.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2023, at Dipolog City.

MARK JOSEPH P. CHIPOCO

(Affiant)
CTC NO.CCI202020765234
Issued at Seres, Katipunan, ZN on May 15, 2023

With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at

Dipolog City.

Doc. No.

Page No.

Book No.

Series of 2023
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, HUBERTO BUOT NAZARIO, of legal age, Filipino, married, and with address of
978 Cuaco Prk. Bougainvilla, Turno, Dipolog City, Zamboanga del Norte after
having been duly sworn in accordance with law, hereby depose and state:

That I was a holder and possessor of a check dated May 19, 2023 issued by PHIL
FIDA to my business ESPINA METAL CRAFT in the amount P39,750.00 with Land
Bank of the Philippines-Pagadian Branch as issuing branch. That the said check
has check number 0003905427;

That I received the check on May 23, 2023 and I slipped it inside my notebook;

That during nighttime, I accidentally put my notebook with the check in it to trash
and was burned with fire;

That after I tried to recover the same but what remains was ashes;

That hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
statements and for the purpose of attesting to the loss of the check.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2023, at Dipolog City. massive

HUBERTO BUOT NAZARIO

(Affiant)
Philippine ID#3937-2915-3075-9238

With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at Dipolog
City.

Doc. No.___

Page No.___

Book No.___

Series of 2023
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, FERNANDO B. MAGNONOT, of legal age, Filipino, married, and with address of

Poblacion, Sibutad, Zamboanga del Norte after having been duly sworn in
accordance with law, hereby depose and state:

That I was a holder and possessor of receipts, eCARs of Estate tax, documentary
stamp taxes, capital gains tax and other taxes of estate of Paterno Magnonot and
others issued by the BIR;

That recently I discovered that my said documents were lost;

That despite effort to recover the same but it was naught. Hence, I considered it
as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
statements and for the purpose of attesting to the loss of the said documents.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2023, at Dipolog City. massive

FERNANDO P. MAGNONOT
(Affiant)
Driver’s License#J01-12-003206

With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at Dipolog
City.

Doc. No.___

Page No.___

Book No.___

Series of 2023
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF RE-ISSUANCE OF RELEASE OF MORTGAGE

I, ENRICO CARUSO S. ROSALES, of legal age, Filipino, married, and with

address of Galas, Dipolog City, Zamboanga del Norte after having been duly
sworn in accordance with law, hereby depose and state:

That I am one of the heirs of late ALEJANDRO SAMSON who is the owner of parcel
of land covered by Transfer Certificate of Title No.T-26542 located at Mias,
Katipunan, Zamboanga del Norte.

That the said parcel of land was used a collateral with Insular Bank of Asia and
America(now BDO);

That it was redeemed by my mother however the release of mortgage was lost;

That this is executed for the re-issuance of release of mortgage with the said
bank(now BDO)

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
statements and for other legal purposes.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2023, at Dipolog City. massive

ENRICO CARUSO S. ROSALES

(Affiant)
OSCA ID#15446-Dipolog City

With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at Dipolog
City.

Doc. No.___

Page No.___

Book No.___

Series of 2023
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ARSENIO P.LLIDO,JR, of legal age, Filipino, married, and with address of

Dicayas, Dipolog City, Zamboanga del Norte after having been duly sworn in
accordance with law, hereby depose and state:

That I was a holder and possessor of a Office of the Senior Citizens Affairs(OSCA)
Identification card(ID) issued by the OSCA of DSWD and Banco de Oro(BDO)
Automated Teller Machine(ATM)card;

That recently I discovered that my OSCA ID and BDO ATM card were lost;

That despite effort to recover the same but it was naught. Hence, I considered it
as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
statements and for the purpose of attesting to the loss of the said OSCA ID and
BDO ATM card.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2023, at Dipolog City. massive

ARSENIO P. LLIDO,JR
(Affiant)
Driver’s License#J04-82-012743

With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at Dipolog
City.

Doc. No.___

Page No.___

Book No.___

Series of 2023
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, EDWIN JARDIN SORRONDA, of legal age, Filipino, married, resident of Magsaysay St., Central Barangay,
Dipolog City, Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and
state:

That I am the children of late Spouses Diogracias Sorronda and Angelita Jardin Sorronda, registered owner of a
parcel of land, more particularly described as follows:

A parcel of land known as Lot No.387-C, covered by Transfer Certificate of Title No.(T-25364)4538 situated at
Poblacion(Central Barangay), Dipolog City, Zamboanga del Norte, containing an area of 76 square meters
issued by the Register of Deeds for Dipolog City.

That I tried to look for the title from our ancestral house after we executed the extra-judicial settlement
document and I even asked my siblings but nothing came into fruition;

That despite effort to recover the same but it was naught.

That I considered it as totally lost.

That I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for the purpose
of attesting to the loss of the said owner’s copy of Transfer Certificate of Title No.(T-25364)4538.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ____th day of _____________ 2023, at
Dipolog City.

EDWIN JARDIN SORRONDA

(Affiant)

Philhealth ID#14-250071724-5

With photo

SUBSCRIBED AND SWORN to before me this ___th day of _________ 2023, at Dipolog City.

DOC.NO. ______
PAGE NO.___

BOOK NO.___

SERIES OF 2023
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, MARIAN C. VALDEZ, of legal age, Filipino, married, and with address of

Diego Silang, Pian, Polanco, Zamboanga del Norte after having been duly
sworn in accordance with law, hereby depose and state:

That I was a holder and possessor of a Tax Identification Number(TIN) card

issued by the Bureau of Internal Revenue;

That recently I discovered that my TIN card was lost;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
TIN card.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2023, at Dipolog City. massive

MARIAN C. VALDEZ
(Affiant)
VIN#7202-0240A-H2073MCV20000-6
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at

Dipolog City.

Doc. No.___

Page No.___

Book No.___

Series of 2023
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, MYLENE ASCURA SAGARIO, of legal age, Filipino, married, a resident of

Bagacayan, Galas, Dipolog City, Zamboanga del Norte after having been
duly sworn in accordance with law, hereby depose and state:

That I was a holder and possessor of a Philippine Passport issued by the

Department of Foreign Affairs;

That on December 1, 2020 I discovered that my passport was lost;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
passport.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2023, at Dipolog City.

MYLENE ASCURA SAGARIO

(Affiant)
Philhealth ID#08-254333461-4
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at

Dipolog City.

Doc. No.___

Page No.___

Book No.___

Series of 2023
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, JOVENCIA D. ORILLA, of legal age, Filipino, widow, a resident of Sta.

Filomena, Dipolog City, Zamboanga del Norte after having been duly sworn
in accordance with law, hereby depose and state:

That I was a holder and possessor of a Certificate of Registration(CR) of

Motor vehicle described as :Make:Kawasaki; Series: CT100S; CR
No.222665785; Engine No.:DUZWEA34210;MV File No.:0901-00000099251,
registered under my name and its Official Receipt(OR);

That recently, I found out that my CR and OR were lost;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
CR and OR.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2023, at Dipolog City.

JOVENCIA D. ORILLA
(Affiant)
Valid ID#________________
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at

Dipolog City.

Doc. No.___

Page No.___

Book No.___

Series of 2023
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, EHRROL S. YANGCO, of legal age, Filipino,married, a resident of Sta.

Filipino, Dipolog City, Zamboanga del Norte after having been duly sworn in
accordance with law, hereby depose and state:

That I was a holder and possessor of a Micro-Entrepreneurs Multi-purpose

Cooperative(MEMCO) Passbook;

That recently, I found out that my MEMCO Passbook was lost;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
Passbook.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2023, at Dipolog City.

EHRROL S. YANGCO
(Affiant)
Driver’s License#G02-01-067423
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at

Dipolog City.

Doc. No.___

Page No.___

Book No.___

Series of 2023
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, KHIMUEL S. DIAMANTE, of legal age, Filipino, single, a resident of Block 12,

Lot 10, VCH, Obay, Polanco, Zamboanga del Norte after having been duly
sworn in accordance with law, hereby depose and state:

That I was a holder and possessor of Driver’s License issued by LTO, Postal
ID issued by PhilPost, Covid-19 Vaccine card, Philippine Identification card
issued by PSA, and Cebuana Lhuillier Card issued by Cebuana Lhuillier
Pawnshop;

That on April 8, 2023, I discovered that my wallet containing those

identification cards was lost;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
Driver’s License issued by LTO, Postal ID issued by PhilPost, Covid-19
Vaccine card, Philippine Identification card issued by PSA, and Cebuana
Lhuillier Card issued by Cebuana Lhuillier Pawnshop .

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2023, at Dipolog City.

KHIMUEL S. DIAMANTE
(Affiant)
Valid ID#__________________
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at

Dipolog City.

Doc. No.___

Page No.___

Book No.___
Series of 2023

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, PRECILA R. CAYANONG, of legal age, Filipino, widow, a resident of Sta.

Isabel, Dipolog City, Zamboanga del Norte after having been duly sworn in
accordance with law, hereby depose and state:

That I was a holder and possessor of a Certificate of Registration(CR) of

Motor vehicle described as :MAKE:Isuzu, CR No. 166673301, Engine No.:4JJ1-
DZ3374, Chassis No.:MPAUCR85H6T100380; Plate No.:YDK977, registered
under my name;

That recently, I found out that my CR was lost;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
CR.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2023, at Dipolog City.

PRECILA R. CAYANONG
(Affiant)
OSCA ID#13145-Dipolog City
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at

Dipolog City.

Doc. No.___

Page No.___

Book No.___

Series of 2023
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF NON-LOSS

I, JOCELYN C. FLORES, of legal age, Filipino, married to Elmo L. Flores, resident of

Sicayab, Dipolog City, Zamboanga del Norte after having been duly sworn in accordance with
law, hereby depose and state:

That I am the owner of a parcel of land, more particularly described as follows:

“A parcel of land known as Lot 2557-D-4-B, Psd-09-072967 situated at Sicayab, Dipolog City
containing an area of two hundred forty-six(246) square meters covered by Transfer Certificate
of Title No.128-2014000560 issued by the Register of Deeds for Dipolog City.”

That I have possession of owner’s duplicate copy of the said parcel of land’s certificate of title
and it was never lost.

That it was used as collateral for a loan and the loan was already paid by the undersigned hence
the title was returned to undersigned;
As such, I am executing this Affidavit of Non-Loss to attest to the truth of the foregoing
statements and for the purpose of annotating this document before the Register of Deeds of
Dipolog City and certifying the non-loss of said certificate of title.

IN WITNESS WHEREOF, I have hereunto affixed my signature this 12th day of April 2023, at
Dipolog City.

JOCELYN C. FLORES

(Affiant)

OSCA ID#16825-issued in Dipolog City

With photo

SUBSCRIBED AND SWORN to before me with affiant showing evidence of identity through
his/her valid ID shown above this 12th day of April 2023, at Dipolog City.

Doc. No.675

Page No.21

Book No.XIX

Series of 2023

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, KIMMY R. PAGADOR, of legal age, Filipino, married, a resident of Upper Turno, Dipolog City,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:
That I was holder and possessor of my late father CEL BAJE REALIZA’s Original Philippine Public
School Teacher Association(PPSTA) MA or MAS65/MRBS/NMRBS/MRBS Plus Policy Contract;

That upon the death of my father I tried to look for the said policy contract;

That however I found it was lost;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said policy contract.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2023, at
Dipolog City.

KIMMY R. PAGADOR
(Affiant)
PRC ID#0957584-Professional Teacher
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at Dipolog City.

Doc. No.

Page No.

Book No.

Series of 2023

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, MARY JANE DAGPIN SUBRADO, of legal age, Filipinomarried, a resident of Sicayab, Dipolog City,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am the sister of FATIMA GONZALES DAGPIN, a graduate of Bachelor of Science in Hotel and
Restaurant Management(BSHRM) at Saint Vincent’s College, Inc.-Dipolog City in year 2017;
That I was holder and possessor of my sister’s Diploma as a graduate of said baccalaureate degree;

That recently I discovered that the original copy of my sister’s Diploma was lost after she asked me to
give the original copy to her, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said document.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2023, at
Dipolog City.

MARY JANE DAGPIN SUBRADO

(Affiant)
PRC ID#1764305-Professional Teacher
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at Dipolog City.

Doc. No.

Page No.

Book No.

Series of 2023

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, CARMELLE DIANNE D. SAPALLEDA, of legal age, Filipino, single, a resident of P.Ramon St.,Biasong,
Dipolog City, Zamboanga del Norte after having been duly sworn in accordance with law, hereby
depose and state:
That I am a holder and possessor of a Globe Sim card with number 09152950777;

That recently, I discovered that my said simcard was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said sim card and thereafter requesting replacement of the
same.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2023, at
Dipolog City.

CARMELLE DIANNE D.SAPALLEDA

(Affiant)
Valid ID#_________________
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023 by above-named person
showing her document of identity as shown above, at Dipolog City.

Doc. No

Page No

Book No

Series of 2023
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, STEPHANIE DAWN DIONO ALIDO, of legal age, Filipino, single, a resident of

Purok 3 Gampis, Sicayab, Dipolog City, Zamboanga del Norte after having
been duly sworn in accordance with law, hereby depose and state:

That I was a holder and possessor of a Philippine Passport issued by the

Department of Foreign Affairs;

That recently I discovered that my passport was lost;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
passport.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2023, at Dipolog City.

STEPHANIE DAWN DIONO ALIDO

(Affiant)
UMID ID#CRN-0111-9490335-5
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at

Dipolog City.

Doc. No.___

Page No.___

Book No.___

Series of 2023
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ROE VAN A. VILLA, of legal age, Filipino, married, a resident of Galas, Dipolog City, Zamboanga del
Norte after having been duly sworn in accordance with law, hereby depose and state:

That I was holder and possessor of my franchise sticker for my tricycle with MTOP DPLG NO.2023-
0175 issued by the Local Government of Dipolog City;

That on 29 March 2023, I discovered that the sticker of tricycle was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said sticker.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2023, at
Dipolog City.

ROE VAN A. VILLA

(Affiant)
Driver’s License#J01-04-001240
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at Dipolog City.

Doc. No.
Page No.

Book No.

Series of 2023

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, NELMA T. MOLIJAR, of legal age, Filipino,single/married, a resident of Obay, Polanco, Zamboanga

del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am holder and possessor of my Diploma as a graduate of baccalaureate degree at Saint

Vincent’s College, Inc.;

That recently I discovered that the original copy of my Diploma was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said document.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2023, at
Dipolog City.

NELMA T. MOLIJAR
(Affiant)
Driver’s License#J01-14-000643
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at Dipolog City.

Doc. No.
Page No.

Book No.

Series of 2023

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, MERAZOL A. DANGGAON, Filipino, of legal age, single, and a resident of

Blk37,Lot 28 VCH, Obay, Polanco, Zamboanga del Norte after having been
duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of receipt with number 0445-2022-00934

dated 13 May 2022 issued by MLhuillier for pawned jewelry describd as
Class Ring 4G DEF YT 102 5.9 in the amount of P9,800.00;

That recently, I found out that my receipt was lost, I tried to locate the
receipts but it was really lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
receipt.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2023, at Dipolog City.

MERAZOL A. DANGGAON
(Affiant)
Valid ID#_________________
With phot

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at

Dipolog City.

Doc. No.__
Page No.__
Book No.__
Series of 2023

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I:ROGELIO ACASO RATILLA, of legal age, Filipino, married, a resident of

Letapan, Polanco, Zamboanga del Norte after having been duly sworn in
accordance with law, hereby depose and state:

That I was a holder and possessor of Driver’s License with number J03-88-
008636 issued by the Land Transportation Office(LTO) and Pag-ibig ATM
Card issued by Pag-ibig;

That on 30 March 2023, I discovered that the said Driver’s License card and
Pag-ibig ATM card including cash inside my wallet was lost after I found out
my motorcycle Ubox was opened forcibly;

That despite effort to recover the same but it was naught. Hence, we
considered it as totally lost.

As such, we are executing this Affidavit of Loss to attest to the truth of the
foregoing statements and for the purpose of attesting to the loss of the said
Driver’s License card and Pag-ibig ATM card.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2023, at Dipolog City.

ROGELIO ACASO RATILLA

(Affiant)
Brgy Bolungisan, Imelda, Zambo Sibugay ID#01
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at

Dipolog City.
Doc. No.

Page No.

Book No.

Series of 2023

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, MARILYN BULAGAO PER, of legal age, Filipino,widow, resident of Dohinob, Roxas, Zamboanga del
Norte after having been duly sworn in accordance with law, hereby depose and state:

That I was the holder and possessor of claim slip of my Professional Regulation Commission(PRC)
identification card as Professional Teacher renewed at PRC Pagadian City;

That I discovered that my claim slip for my PRC license card was lost;

That despite effort to recover the same but it was naught.

That I/he considered it as totally lost.

That I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for the purpose
of attesting to the loss of the said claim slip.

IN WITNESS WHEREOF, I have hereunto affixed my signature this __th day of _______ 2023, at Dipolog
City.

MARILYN BULAGAO PER

(Affiant)

UMID ID#CRN-006-0094-7760-9

SUBSCRIBED AND SWORN to before me this ___th day of ________ 2023, at Dipolog City.

DOC.NO. ______

PAGE NO.___

BOOK NO.___

SERIES OF 2023
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, JOSEPH VELASCO BUSTALIÑO, of legal age, Filipino, single, a resident of

184-A Magsaysay St., Miputak, Dipolog City, Zamboanga del Norte after
having been duly sworn in accordance with law, hereby depose and state:

That I was a holder and possessor of a Certificate of Registration(CR) of

Motor vehicle described as :MAKE:Yamaha, CR No. 335003620, Engine
No.:E31TE-0094024, Series:Mio Sporty 40CI, registered under my name;
And another CR for motor vehicle with CR No.289307981;

That recently, I found out that my CR was lost;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
CR.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2023, at Dipolog City.

JOSEPH VELASCO BUSTALIÑO

(Affiant)
DL#J01-87-006943
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at

Dipolog City.

Doc. No.___

Page No.___

Book No.___
Series of 2023

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, DULCITA SIBYA DIAMANTE, of legal age, Filipino, married, resident of Block 12, Lot 10, VCH, Obay,
Polanco, Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am the daughter of late Spouses Bernardita Cordero and Benjamin Sibya, registered owner of a parcel of
land, more particularly described as follows:

A parcel of land known as Lot No.G, Psd-145987, covered by Transfer Certificate of Title No.T-17924 situated
at Poblacion, Roxas, Zamboanga del Norte, containing an area of 1,283 square meters issued by the Register of
Deeds for Zamboanga del Norte.

That the owner’s copy of the title was turned over to me by older sibling however when I and my siblings were
about to partition the said parcel of land, I discovered that the owner’s copy of the title was lost;

That despite effort to recover the same but it was naught.

That I considered it as totally lost.

That I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for the purpose
of attesting to the loss of the said owner’s copy of Transfer Certificate of Title No.T-17924.

IN WITNESS WHEREOF, I have hereunto affixed my signature this 29th day of September 2022, at Dipolog
City.

DULCITA SIBYA-DIAMANTE

(Affiant)

PRC ID#0653058 valid until 10/25/2025

With photo

SUBSCRIBED AND SWORN to before me this 29th day of September 2022, at Dipolog City.

DOC.NO. 4064

PAGE NO.75

BOOK NO.XVI

SERIES OF 2022
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, DAREN MONTES DONIO, of legal age, Filipino, single, a resident of Purok

Villa Sta. Rosa, Turno, Dipolog City, Zamboanga del Norte after having been
duly sworn in accordance with law, hereby depose and state:

That I was a holder and possessor of a Philippine Passport issued by the

Department of Foreign Affairs;

That in December 2022 we experienced heavy flood in our house and my

passport was kept in a part of our house that was flooded and I discovered
that my passport was lost;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
passport.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2023, at Dipolog City.

DAREN MONTES DONIO

(Affiant)
VIN#72020185AF1792DMD20000
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at

Dipolog City.

Doc. No.___

Page No.___

Book No.___
Series of 2023

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, RUEL SAYON MAGALLANES, Filipino, of legal age, married , and a resident

of Rizalina, Rizal, Zamboanga del Norte after having been duly sworn in
accordance with law, hereby depose and state:

That I was a holder of official receipt issued by Paragon Hardware for

Chainsaw with Serial No.20-1237889;

That recently, I found out that my receipt was lost, I tried to locate the
receipts but it was really lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
receipt.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2023, at Dipolog City.

RUEL SAYON MAGALLANES

(Affiant)
Driver’s License#J01-12-001905
With phot

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at

Dipolog City.

Doc. No.__
Page No.__
Book No.__
Series of 2023

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, THELMA R. BAGARINAO, Filipino, of legal age, widow , and a resident of

Purok Dancing Lady, Gulayon, Dipolog City, Zamboanga del Norte after
having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of receipt with number 0447-2023-00402

dated 5 February 2023 issued by MLhuillier for pawned jewelry describd as
YG Pendant Def 18K 5.40g in the amount of P13,500.00;

That recently, I found out that my receipt was lost, I tried to locate the
receipts but it was really lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
receipt.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2023, at Dipolog City.

THELMA R. BAGARINAO
(Affiant)
TIN#776-280-823
With phot

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at

Dipolog City.

Doc. No.__
Page No.__
Book No.__
Series of 2023

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, FELIX BAGUNDOL RONULFO,JR, of legal age, Filipino, married, a resident

of Mauswagon, La Libertad, Zamboanga del Norte, after having been duly
sworn in accordance with law, hereby depose and state:

That I was a holder and possessor of an Public Safety Savings and Loan
Association Inc.PSSLAI Identification Card(ID) issued by PSSLAI;

That recently, while I was trying to look for the said PSSLAI ID from where I
kept it, I found out that the PSSLAI ID was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost;

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

foregoing statements and for the purpose of attesting to the loss of the said
PSSLAI ID.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2023, at Dipolog City.

FELIX BAGUNDOL RONULFO,JR

(Affiant)
PNP ID#21L3000094
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at

Dipolog City.

Doc No. _____

Page No. _____
Book No. ____
Series of 2023
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, RODRIGO DAGPIN ELOLA, of legal age, Filipino, married, a resident of

Estaka, Dipolog City, Zamboanga del Norte, after having been duly sworn in
accordance with law, hereby depose and state:

That I am a holder and possessor of a National Certificate known as NC II in

Heavy Equipment Operation(Wheel Loader) issued by TESDA;

That recently, while I was trying to look for the said certificate from my file
where I kept it, I found out that the original document was lost, and could
not be found;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost;

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

foregoing statements and for the purpose of attesting to the loss of the said
certificate.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

March 2023, at Dipolog City.

RODRIGO DAGPIN ELOLA

(Affiant)
Driver’s License#J01-87-006705
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of March 2023, at

Dipolog City.

Doc. No

Page No

Book No
Series of 2023

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, DORIS ALVARICO OLANDAG, of legal age, Filipino, married, a resident of Obay, Polanco, Zamboanga
del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of a Sales Invoice with Number 29482 and Collection Receipt with
Number 148658 issued by Imperial Appliance Plaza- Dipolog City for Sony TV with Serial No.4718225
which I purchased .

That recently, I discovered that the Sales Invoice and Collection Receipt were lost, and could not be
found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said Sales Invoice and Collection Receipt.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2023, at
Dipolog City.

DORIS ALVARICO OLANDAG

(Affiant)
Driver’s License#J01-19-001903
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2023

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, MARY CRIS BINOYA ALBINA, of legal age, Filipino, single/married, a resident of Block 6, Lot 36, Phase
2, Gulayon, Dipolog City, Zamboanga del Norte after having been duly sworn in accordance with law,
hereby depose and state:

That I am a holder and possessor of an Automated Teller Machine(ATM) card issued by Land Bank of
the Philippines(LBP) with Account number 0196453415 .

That recently, I discovered that the LBP ATM card was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said LBP ATM card and thereafter requesting replacement
thereon.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2023, at
Dipolog City.

MARY CRIS BINOYA ALBINA

(Affiant)
Driver’s License#J01-21-200356
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2023

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, MARIA MELINDA P. REDULLA, married to Domingo Redulla,Jr, of legal age,

Filipino, resident of Sta.Filomena, Dipolog City, after having been duly sworn in
accordance with law, hereby depose and state:

That I was a holder and possessor of a Passbook for an account number

10A006985 issued by Zamboanga del Norte Cooperative Bank(ZNCoop Bank);

That recently, while I was trying to look for the said ZNCoop Bank Passbook from
where I kept it, I found out that the ZNCoop Bank Passbook was lost, and could
not be found;

That despite effort to recover the same but it was naught. Hence, I considered it
as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
statements and for the purpose of attesting to the loss of the said ZNCoop Bank
Passbook.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2023, at Dipolog City.

MARIA MELINDA P.REDULLA

(Affiant)
Phil.ID#8092530187431752
 With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at Dipolog
City.

Doc No. _____

Page No. _____
Book No. ____
Series of 2023

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, MARIE C. REFUGIO, Filipino, of legal age, married , and a resident of Tabuk

tulay, Dicayas Dipolog City, Zamboanga del Norte after having been duly
sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of receipts with number 0143-2022-00853

and 0143-2022-00852, both dated 9 August 2022 issued by MLhuillier for
pawned jewelries identified as YG Necklace Def 18K 8.5 grams in the
amount of P20,650.00 and YG Bracelet Def 18K 5 grams in the amount of
P11,800.00, respectively;
That recently, I found out that my receipts were lost, I tried to locate the
receipts but it was really lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
receipts.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2023, at Dipolog City.

MARIE C. REFUGIO
(Affiant)
Driver’s License#J01-00-034319
With phot

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at

Dipolog City.

Doc. No.__
Page No.__
Book No.__
Series of 2023

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF CONFORMITY

We: CARMEN ROYOS MICUBO-BARBASO, SEGUNDINO ARNADO MICUBO,JR.(as heir of

late Segundino Micubo), LEONILA M. ALABATA, AUDIFAZ M. CUBERO, ANDRES R.
MICUBO, JR., CONSORCIA CASIA FLORES(as heir of late Divina Micubo Casia), all of legal age,
all Filipinos, all residents of Siocon, Zamboanga del Norte after having been duly sworn in
accordance with law, hereby depose and state:

That we are the heirs/children of Marcelina Royos. That three of the children of late Marcelina Royos
namely: Divina Micubo Casia, Florencio Micubo and Segundino Micubo were dead already and they
were duly represented;
That in the Deed of Extrajudicial Settlement of Estate of Melchor Royos and Martina Yebes a parcel of
land known as Lot 495 of the Cadastral Survey of Dipolog situated at Estaka, Dipolog City, containing
an area of 395 square meters covered by Transfer Certificate of Title No.(T-5877)1497 issued by the
Register of Deeds for Dipolog City was adjudicated to the Heirs of Marcelina Royos notarized by Atty.
Prim. L. Abarquez III per Doc. No.144, Page No.77, Book No. LXXXI, Series of 2011(please see
attached).

That a petition was filed for replacement of lost title through Atty. Primitivo Abarquez III. After the
owner’s copy of the title was issued, it was given to late Florencio Royos-Micubo, one of the
children/heirs of Marcelina Royos, for safekeeping;

That however we were informed by it was lost by Nerissa S. Micubo so she executed an affidavit of
loss.

That as heirs of Marcelina Royos, we hereby consent and confirm to the act of Nerissa S. Micubo in
replacing the owner’s copy of the title after it was lost again.

That we hereby attest the truthfulness of foregoing statements.

IN WITNESS WHEREOF, we have hereunto affixed our signatures this ___ day of __________ 2023,
at Dipolog City.

CARMEN ROYOS MICUBO-BARBASO, SEGUNDINO ARNADO MICUBO,JR.,

LEONILA M. ALABATA, AUDIFAZ M. CUBERO, ANDRES R. MICUBO, JR.,

CONSORCIA CASIA FLORES

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at Dipolog City.

Doc. No.
Page No.
Book No.
Series of 2023

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, LEIZLE FIEL OMILIG, of legal age, Filipino,married, a resident of Olingan, Dipolog City, Zamboanga del
Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am holder and possessor of my Diploma as a graduate of baccalaureate degree of Bachelor of

Science in Nursing at Dipolog Medical Center College Foundation, Inc., Dipolog City, as well as my PRC
license as registered nurse and my board rating and other documents relative to my profession
issued by PRC;

That I discovered that the original copy of my Diploma, PRC license, Board Rating and other PRC
related papers were lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;
As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said documents.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2023, at
Dipolog City.

LEIZLE FIEL OMILIG

(Affiant)
Valid ID#_____________________
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at Dipolog City.

Doc. No.

Page No.

Book No.

Series of 2023

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF NON-RECEIPT OF CHECK

I, GEOFFREY OCAMPOS TALPIS, of legal age, Filipino, married, a resident of

Zamoras St Ext., Estaka, Dipolog City, Zamboanga del Norte after having
been duly sworn in accordance with law, hereby depose and state:

That I was an applicant for educational loan at the Social Security

System(SSS) in February 2022;

That I have been waiting for a long period of time for the release of the
check of my loan however I was informed that a check was issued already.
The check has a number 4967140;
That I have not received the check of the educational loan I applied for nor
encashed it;

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

statements.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2023, at Dipolog City.

GEOFFREY OCAMPOS TALPIS

(Affiant)
Driver’s License#J03-97-022054
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at

Dipolog City.

Doc. No.___

Page No.___

Book No.___

Series of 2023

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, RONELYN S. PATAG, of legal age, Filipino, married, a resident of Larayan, Dapitan City, Zamboanga
del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am the mother of KATE VALERIE S. PATAG who graduated the baccalaureate course at Silliman
University, Dumaguete City.

That my daughter was issued a copy of her Honorable Dismissal dated June 5, 2018 from the said
university. That she later went to Canada.
That I became safekeeper and possessor of the Honorable Dismissal, and her other school related
documents.

That recently my child called me to ask for her documents but I forgot the place where I kept it and I
could not retrieve it anymore.

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said Honorable Dismissal and thereafter requesting
replacement thereon.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2023, at
Dipolog City.

RONELYN S. PATAG
(Affiant)
Passport No.P1744385B valid until 26 May 2029

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2023
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I:RONALD GALLO CREUS, of legal age, Filipino, married, a resident of

Poblacion South, Polanco, Zamboanga del Norte after having been duly
sworn in accordance with law, hereby depose and state:

That I was a holder and possessor of Driver’s License issued by the Land
Transportation Office(LTO);

That in February 2023, I discovered that the said Driver’s License card was
lost;

That despite effort to recover the same but it was naught. Hence, we
considered it as totally lost.

As such, we are executing this Affidavit of Loss to attest to the truth of the
foregoing statements and for the purpose of attesting to the loss of the said
Driver’s License card.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2023, at Dipolog City.

RONALD GALLO CREUS

(Affiant)
PNP ID#21I0200397

With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at

Dipolog City.

Doc. No.

Page No.

Book No.

Series of 2023
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I:ALVER CABAHUG AGEAS, of legal age, Filipino, married, a resident of

Sta.Isabel, Dipolog City, Zamboanga del Norte after having been duly sworn
in accordance with law, hereby depose and state:

That I was a holder and possessor of Unified Multipurpose Identification

Card(UMID) issued by Government Service Insurance System(GSIS);

That recently, I discovered that the said UMID card was lost;

That despite effort to recover the same but it was naught. Hence, we
considered it as totally lost.

As such, we are executing this Affidavit of Loss to attest to the truth of the
foregoing statements and for the purpose of attesting to the loss of the said
UMID card.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2023, at Dipolog City.

ALVER CABAHUG AGEAS

(Affiant)
Driver’s License#G01-97-218689
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at

Dipolog City.

Doc. No.

Page No.

Book No.

Series of 2023
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, LOVELYN GRACE S. LAZOLA, of legal age, Filipino, single, a resident of Dicayas, Dipolog City,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of an Automated Teller Machine(ATM) cash card issued by Land
Bank of the Philippines(LBP)-Dipolog City Branch through DSWD for 4Ps.

That in July 2022 our house was razed by fire, I discovered that the LBP ATM card was lost through the
fire, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said LBP ATM card and thereafter requesting replacement
thereon.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2023, at
Dipolog City.

LOVELYN GRACE S. LAZOLA

(Affiant)
DepEd Student ID#______________

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2023
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, JECIL HANTONG BONGCAO, of legal age, Filipino, married, a resident of Purok

Gampis, Sicayab, Dipolog City, Zamboanga del Norte, after having been duly
sworn in accordance with law, hereby depose and state:

That I am holder and possessor of a Driver’s License with its Official Receipt(OR)
issued by Land Transportation Office(LTO);

That recently I discovered that my said driver’s license and its OR and OR were
lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it
as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
statements and for the purpose of attesting to the loss of the said Driver’s License
and OR issued by LTO.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

_______ 202__, at Dipolog City.

JECIL HANTONG BONGCAO

(Affiant)
VIN#7202-0103A-F3085JHB20000-4
With photo

SUBSCRIBED AND SWORN to before me this ___ day of ________ 202__, at Dipolog
City.

DOC.NO.

PAGE NO.

BOOK NO.

SERIES OF 2023
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ROMEO R. AGIAS, of legal age, Filipino, a resident of Poblacion North, Polanco, Zamboanga del
Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am the holder and possessor of an original copy of BIR Revenue Official receipt No. ROR2021-
004484-000021 for the estate tax payments of estate of Lourdes R. Agias issued by the Bureau
Internal Revenue.

That I discovered that above-mentioned document was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said document

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2023, at
Dipolog City.

ROMEO R. AGIAS
(Affiant)
Valid ID#_____________
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2023
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF CONFORMITY

We: CARMEN ROYOS MICUBO-BARBASO, SEGUNDINO ARNADO MICUBO,JR.(as heir of

late Segundino Micubo), LEONILA M. ALABATA, AUDIFAZ M. CUBERO, ANDRES R.
MICUBO, JR., CONSORCIA CASIA FLORES(as heir of late Divina Micubo Casia), all of legal age,
all Filipinos, all residents of Siocon, Zamboanga del Norte after having been duly sworn in
accordance with law, hereby depose and state:

That we are the heirs/children of Marcelina Royos. That three of the children of late Marcelina Royos
namely: Divina Micubo Casia, Florencio Micubo and Segundino Micubo were dead already and they
were duly represented;

That in the Deed of Extrajudicial Settlement of Estate of Melchor Royos and Martina Yebes a parcel of
land known as Lot 495 of the Cadastral Survey of Dipolog situated at Estaka, Dipolog City, containing
an area of 395 square meters covered by Transfer Certificate of Title No.(T-5877)1497 issued by the
Register of Deeds for Dipolog City was adjudicated to the Heirs of Marcelina Royos notarized by Atty.
Prim. L. Abarquez III per Doc. No.144, Page No.77, Book No. LXXXI, Series of 2011(please see
attached).

That a petition was filed for replacement of lost title through Atty. Primitivo Abarquez III. After the
owner’s copy of the title was issued, it was given to late Florencio Royos-Micubo, one of the
children/heirs of Marcelina Royos, for safekeeping;

That however we were informed by it was lost by Nerissa S. Micubo so she executed an affidavit of
loss.

That as heirs of Marcelina Royos, we hereby consent and confirm to the act of Nerissa S. Micubo in
replacing the owner’s copy of the title after it was lost again.

That we hereby attest the truthfulness of foregoing statements.

IN WITNESS WHEREOF, we have hereunto affixed our signatures this ___ day of __________ 2023,
at Dipolog City.

CARMEN ROYOS MICUBO-BARBASO, SEGUNDINO ARNADO MICUBO,JR.,

LEONILA M. ALABATA, AUDIFAZ M. CUBERO, ANDRES R. MICUBO, JR.,

CONSORCIA CASIA FLORES

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at Dipolog City.

Doc. No.
Page No.
Book No.
Series of 2023

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, EUMENA BULJATIN ELUMBARING, of legal age, Filipino, single/married, a

resident of Miputak, Dipolog City, Zamboanga del Norte, after having been duly
sworn in accordance with law, hereby depose and state:

That I am holder and possessor of a Driver’s License with its Official Receipt(OR)
issued by Land Transportation Office(LTO);

That recently I discovered that my said driver’s license and its OR and OR were
lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it
as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
statements and for the purpose of attesting to the loss of the said Driver’s License
and OR issued by LTO.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

_______ 202__, at Dipolog City.

EUMENA BULJATIN ELUMBARING

(Affiant)
UMID ID#CRN-006-0110-6460-2
With photo

SUBSCRIBED AND SWORN to before me this ___ day of ________ 202__, at Dipolog
City.

DOC.NO.

PAGE NO.

BOOK NO.
SERIES OF 2023

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ROCHEL A TROPICO, of legal age, Filipino, married, a resident of Purok 1,

Katipa, Lopez Jaena, Misamis Occidental, after having been duly sworn in
accordance with law, hereby depose and state:

That I am the keeper of the Business Permit and Business Plate of THREE’JS
WELLNESS PRODUCTS TRADING, located at Herrera St., Miputak, Dipolog
City, issued by LGU-Dipolog City, registered under my name;

That recently, while I was trying to look for the said business permit and
plate from where I kept it, I found out that the business plate and permit
were lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost;

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

foregoing statements and for the purpose of attesting to the loss of the said
business permit and plate.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2023, at Dipolog City.

ROCHEL A. TROPICO
(Affiant)
Driver’s License#K12-07-000742
With Photo
SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at
Dipolog City.

Doc No. _____

Page No. _____
Book No. ____
Series of 2023

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, KENNETH JAMES R. DIAZ, of legal age, Filipino, single, a resident of Fatima,Liloy,

Zamboanga del Norte, after having been duly sworn in accordance with law,
hereby depose and state:

That I am holder and possessor of a Certificate of Registration of motor vehicle

with Engine No.JF78E7356423 and Chassis No. K81N4012169, Make: Honda, CR
No.42166420-2 and its Official Receipt(OR) issued by Land Transportation
Office(LTO);

That recently, I discovered that said Certificate of Registration and OR were lost,
and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it
as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
statements and for the purpose of attesting to the loss of the said Certificate of
Registration and OR issued by LTO.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

_______ 202__, at Dipolog City.

KENNETH JAMES R. DIAZ

(Affiant)
Driver’s License#J07-29-005574
With photo
SUBSCRIBED AND SWORN to before me this ___ day of ________ 202__, at Dipolog
City.

DOC.NO.

PAGE NO.

BOOK NO.

SERIES OF 2023

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, DIOSCORO E. CIMAFRANCA of legal age, Filipino, married, a resident of Olingan, Dipolog City,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of the original copy Motorized Tricycle Operator’s Permit(MTOP)
issued by Local Government of Dipolog City with MTOP DPLG NO. 2022-0346 with Expiry date of
February 2023 registered under my name.

That recently while I was trying to look for the MTOP of my tricycle, I found out that the it was lost,
and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said MTOP.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2023, at
Dipolog City.

DIOSCORO E. CIMAFRANCA
(Affiant)
Valid ID#_______________
 With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at Dipolog City.

Doc. No
Page No
Book No
Series of 2023

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ARIANE MAE VILLAMIL PAGLINAWAN, of legal age, Filipino, married, a

resident of Gampis, Sicayab, Dipolog City, Zamboanga del Norte, after
having been duly sworn in accordance with law, hereby depose and state:

That I was a holder and possessor of an AFPSLAI Red Passbook issued by

AFPSLAI;

That recently, while I was trying to look for the said AFPSLAI Passbook from
where I kept it, I found out that the AFPSLAI Passbook was lost, and could
not be found;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost;

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

foregoing statements and for the purpose of attesting to the loss of the said
AFPSLAI Red Passbook.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2023, at Dipolog City.
 ARIANE MAE VILLAMIL PAGLINAWAN
(Affiant)
PNP ID Card No.21C2300380
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at

Dipolog City.

Doc No. _____

Page No. _____
Book No. ____
Series of 2023

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, NERISSA SANDUETA MICUBO, of legal age, Filipino, widow, resident of Estaka, Dipolog City,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am the surviving spouse of Florencio Micubo,owner of a parcel of land, more particularly
described as follows:

“A parcel of land known as Lot 1, Psd-241185 situated at Balili, Siocon, Zamboanga del Norte,
containing an area of 119,999 square meters covered by Transfer Certificate of Title No.T-31860
issued by the Register of Deeds for Zamboanga del Norte.”

That recently I processed the titling of the remaining portion of the said parcel of land however I was
asked for the owner’s copy and I could no longer where I kept the said owner’s copy;

That despite effort to recover the same but it was naught.

That I considered it as totally lost.

That I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for the
purpose of attesting to the loss of the said owner’s copy of Transfer Certificate of Title No.T-31860.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2023, at
Dipolog City.
 NERISSA SANDUETA MICUBO

(Affiant)

OSCA ID#0529-Dipolog City

With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at Dipolog City.

Doc. No.
Page No.
Book No.
Series of 2023

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

NOTARIZED AFFIDAVIT

I:CESARIO V. SAYRE, of legal age, Filipino, married, a resident of Turno,

Dipolog City, Zamboanga del Norte after having been duly sworn in
accordance with law, hereby depose and state:

That I am the Executive Director of Asset-Based Community Development

with Equity Foundation;

That we have operated and maintained an organic and chemical-free farm

located at Villahermosa, Polanco, Zamboanga del Norte covered by Transfer
Certificate of Title No.T-33944;

That as farm operator, I hereby certify that the said organic and chemical -
free farm has passed all the standards required for a Learning Site for
Agriculture(LSA) by the Department of Agriculture;

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

statements.
IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of
__________ 2023, at Dipolog City.

CESARIO V. SAYRE
(Affiant)
UMID ID#CRN-0111-7317106-9
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at

Dipolog City.

Doc. No.

Page No.

Book No.

Series of 2023

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF COMPLETION

I:CLIFF DUA MONTILLA, of legal age, Filipino, married to Melna Costanilla

Sanchez, a resident of Sinaman, Dipolog City, Zamboanga del Norte after
having been duly sworn in accordance with law, hereby depose and state:

That I am the applicant of housing loan with the Pag-ibig Fund;

That the said housing loan was secured by Transfer Certificate of Title
No.128-2021000757 located at Sinaman, Dipolog City;

That the said house building is now completed and finished in accordance
with the plans submitted to the Pag-ibig Funds

As such, we are executing this Affidavit to attest to the truth of the

foregoing statements.
IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of
__________ 2023, at Dipolog City.

CLIFF DUA MONTILLA

(Affiant)
PRC ID#0063401
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at

Dipolog City.

Doc. No.

Page No.

Book No.

Series of 2023

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I:ALINE B. PATAGOC, of legal age, Filipino, married, a resident of Purok D’

Oro, Olingan, Dipolog City, Zamboanga del Norte after having been duly
sworn in accordance with law, hereby depose and state:

That I was a holder and possessor of Automated Teller Machine(ATM) card

issued by Land Bank of the Philippines which was my temporary GSIS card;

That recently, I discovered that the said ATM card was lost;

That despite effort to recover the same but it was naught. Hence, we
considered it as totally lost.

As such, we are executing this Affidavit of Loss to attest to the truth of the
foregoing statements and for the purpose of attesting to the loss of the said
ATM card.
IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of
__________ 2023, at Dipolog City.

ALINE B. PATAGOC
(Affiant)
PSA Employee ID#095323
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at

Dipolog City.

Doc. No.

Page No.

Book No.

Series of 2023

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, JECONIAH B. DELANTAR, of legal age, Filipino, single, a resident of Turno,

Dipolog City, Zamboanga del Norte, after having been duly sworn in accordance
with law, hereby depose and state:

That I am holder and possessor of an updated Driver’s License with its Official
Receipt(OR) issued by Land Transportation Office(LTO);

That recently I discovered that my said driver’s license and its OR and OR were
lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it
as totally lost;
As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
statements and for the purpose of attesting to the loss of the said Driver’s License
and OR issued by LTO.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

_______ 202__, at Dipolog City.

JECONIAH B. DELANTAR
(Affiant)
JRMSU School ID#11922
With photo

SUBSCRIBED AND SWORN to before me this ___ day of ________ 202__, at Dipolog
City.

DOC.NO.

PAGE NO.

BOOK NO.

SERIES OF 2023

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I:AMILODDEN T. AHIL, of legal age, Filipino, married, a resident of Sianib,

Polanco, Zamboanga del Norte after having been duly sworn in accordance
with law, hereby depose and state:
That I was a holder and possessor of Automated Teller Machine(ATM) card
issued by Development Bank of the Philippines-Dipolog City Branch with
account number 8155190200;

That recently, I discovered that the said ATM card was lost;

That despite effort to recover the same but it was naught. Hence, we
considered it as totally lost.

As such, we are executing this Affidavit of Loss to attest to the truth of the
foregoing statements and for the purpose of attesting to the loss of the said
ATM card.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2023, at Dipolog City.

AMILODDEN T. AHIL
(Affiant)
OSCA ID#20-04781-Polanco,ZN
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at

Dipolog City.

Doc. No.

Page No.

Book No.

Series of 2023
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

SWORN STATEMENT

I, _______________________, of legal age, Filipino, single/married, with office

address of DAR Province of Zamboanga del Norte Office, Sta. Isabel, Dipolog
City, after having been duly sworn in accordance with law, hereby depose
and state:

That I am an employee of Department of Agrarian Reform

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

foregoing statements and for the purpose of attesting to the loss of the said
UMID card and request the replacement of the said card.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2023, at Dipolog City.

JOSE BONETE CACANANDO,JR

(Affiant)
OSCA ID#22177-Dipolog City
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at

Dipolog City.

Doc.No.

Page No.

Book No.

Series of 2023
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, JOSE BONETE CACANANDO,JR., of legal age, Filipino, married, a resident

of Estaka, Dipolog City Zamboanga del Norte, after having been duly sworn
in accordance with law, hereby depose and state:

That I am a holder and possessor of a Unified Multipurpose Identification

Card(UMID) issued by Government Service Insurance System(GSIS);

That l received my UMID card and when I tried to look for it but it was
nowhere to be found thus I considered it as lost;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost;

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

foregoing statements and for the purpose of attesting to the loss of the said
UMID card and request the replacement of the said card.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2023, at Dipolog City.

JOSE BONETE CACANANDO,JR

(Affiant)
OSCA ID#22177-Dipolog City
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at

Dipolog City.

Doc.No.

Page No.
Book No.

Series of 2023

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I:DIOSDADA PANGASIAN CATIPAY, of legal age, Filipino, widow, a resident of

Purok Parpagayo, Gulayon, Dipolog City, Zamboanga del Norte after having
been duly sworn in accordance with law, hereby depose and state:

That I was a holder and possessor of ATM card issued by LandBank of the
Philippines which was used for benefits of 4Ps of DSWD;

That recently, I discovered that the said ATM card was lost;

That despite effort to recover the same but it was naught. Hence, we
considered it as totally lost.

As such, we are executing this Affidavit of Loss to attest to the truth of the
foregoing statements and for the purpose of attesting to the loss of the said
ATM card.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2023, at Dipolog City.

DIOSDADA P. CATIPAY
(Affiant)
Phil.ID#4305-2689-0647-8196
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at

Dipolog City.

Doc. No.
Page No.

Book No.

Series of 2023

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, FELITA R. ACOYMO, of legal age, Filipino, single, a resident of Relocation

Site, Dicayas, Dipolog City, Zamboanga del Norte after having been duly
sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of Automated Teller Machine(ATM) card

with Account Number 0517-028-193 issued by Land Bank of the Philippines-
Dipolog City Branch;

That on January 28, 2023, I discovered that my said ATM card was lost;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
ATM card.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day

of_____2023, at Dipolog City.

FELITA R. ACOYMO
(Affiant)
UMID ID#CRN-006-0075-3622-5
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at

Dipolog City.

Doc. No.

Page No.
Book No.

Series of 2023

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ERLINDA MANUGAS ABAD, of legal age, Filipino, a resident of Isis, Polanco,

Zamboanga del Norte after having been duly sworn in accordance with law,
hereby depose and state:

That I was holder and possessor of OSCA Identification(ID) card issued by Office of
Senior Citizen’s Affairs(OSCA).

That recently, I discovered that my said OSCA ID card was lost, and could not be
found;

That despite effort to recover the same but it was naught. Hence, I considered it
as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
statements and for the purpose of attesting to the loss of the said OSCA ID card.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

February 2023, at Dipolog City.

ERLINDA MANUGAS ABAD

(Affiant)
AFP Legal Beneficiary ID#B15-E-46068
With photo

SUBSCRIBED AND SWORN to before me this ___ day of February 2023, at Dipolog
City.

DOC.NO.

PAGE NO.

BOOK NO.
SERIES OF 2023

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

We:RUBEN L. COLALJO and RICHARD S. COLALJO, both of legal age, both Filipinos,
both residents of Upper Turno, Dipolog City, Zamboanga del Norte after having
been duly sworn in accordance with law, hereby depose and state:

That we were the holders and possessors of a Passbook issued by Rural Bank of
Rizal- Dipolog City Branch with account number 007-001-0251;

That recently, we discovered that said passbook was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, we considered it
as totally lost;

As such, we are executing this Affidavit of Loss to attest to the truth of the
foregoing statements and for the purpose of attesting to the loss of the said
passbook.

IN WITNESS WHEREOF, we have hereunto affixed our signatures this ___ day of
_______ 202__, at Dipolog City.

RUBEN L. COLALJO/RICHARD S. COLALJO

(Affiant)
OSCA ID#11136-Dipolog City/DL#J01-07-003302
With photo

SUBSCRIBED AND SWORN to before me this ___ day of ________ 202__, at Dipolog
City.

DOC.NO.

PAGE NO.

BOOK NO.
SERIES OF 2023

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

We, CARMEN GARGANERA-DIONGLAY, CHRISTIAN VAL G. DIONGLAY, TEODORO G. DIONGLAY III, and
AILEEN CARMENCITA DIONGLAY-BAJAS, all of legal age, all Filipinos, all single except Carmen who is
widow and Aileen Carmencita who is married), all residents of Sicayab, Dipolog City, Zamboanga del
Norte after having been duly sworn in accordance with law, hereby depose and state:

That we were holders and possessors of a BIR Stamped Extrajudicial Partiton with Simultaneous Sale
and Affidavit of Publication of said Extrajudicial Partition with Simultanenous Sale notarized by Jonald
C. Napigquit per Doc. No.3532, Page No. 69, Book No. 70, Series of 2019 with its clippings issued by a
local newspaper;

That we learned that our document and affidavit with clippings was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, we considered it as totally lost;

As such, we are executing this Affidavit of Loss to attest to the truth of the foregoing statements and
for the purpose of attesting to the loss of the said document and affidavit with clippings.

IN WITNESS WHEREOF, we have hereunto affixed our signatures this ___ day of __________ 2023, at
Dipolog City.

CARMEN G. DIONGLAY/CHRISTIAN VAL G. DIONGLAY/TEODORO G. DIONGLAY III.AILEEN CARMENCITA BAJAS

(Affiants)
OSCA ID#000632-Dapitan City/BFP ID#D29041/TIN#933-784-947/TIN#928-971-947
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at Dipolog City.
Doc. No.

Page No.

Book No.

Series of 2023

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, RYAN C. ALMIROL, of legal age, Filipino, single, resident of Pian, Polanco, Zamboanga del Norte after
having been duly sworn in accordance with law, hereby depose and state:

That I am the holder and possessor of owner’s copy of certificate of title for parcel of land which is owned by
my late grandfather Julian Almerol. That my said grandfather had a child named Quirino Almirol, my father
who is already dead.

That the said parcel of land is known as:

“A parcel of land Plan H-201658, situated at Manil(now Pitogo), Mandih, Sindangan(now Leon Postigo),
Zamboanga del Norte containing an area of 157,152 square meters covered by Original Certificate of Title
No.P-369.”

That the original owner’s copy of the title was turned over to me by my father before he died;

That I have lost the owner’s copy of said parcel of land ;

That despite effort to recover the same but it was naught.

That I considered it as totally lost.

That I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for the purpose
of attesting to the loss of the said owner’s copy of Original Certificate of Title No.P-369.

IN WITNESS WHEREOF, I have hereunto affixed my signature this __th day of _______ 2023, at Dipolog
City.

Ww2

RYAN C. ALMIROL

(Affiant)

Phil ID#3257-2675-9476-8904

SUBSCRIBED AND SWORN to before me this ___th day of ________ 2023, at Dipolog City.

DOC.NO. ______

PAGE NO.___

BOOK NO.___

SERIES OF 2023

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, JOPE ADALLA DONGON, of legal age, Filipino, single, a resident of Ramon

Magsaysay, Salug, Zamboanga del Norte, after having been duly sworn in
accordance with law, hereby depose and state:

That I am holder and possessor of an updated Driver’s License with its Oficial
Receipt(OR) issued by Land Transportation Office(LTO);

That while I was driving a motor vehicle with Plate number CBN5250 on January 1,
2023 I encountered an accident and I discovered that my said driver’s license and
its OR and OR were lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it
as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
statements and for the purpose of attesting to the loss of the said Driver’s License
and OR issued by LTO.
IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of
_______ 202__, at Dipolog City.

JOPE ADALLA DONGON

(Affiant)
Voter’s ID#7213-0063B-K0886JAD1000
With photo

SUBSCRIBED AND SWORN to before me this ___ day of ________ 202__, at Dipolog
City.

DOC.NO.

PAGE NO.

BOOK NO.

SERIES OF 2023

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ALLEN FRANS T. QUISEL, of legal age, Filipino, single, a resident of Brgy.

Silawe, Polanco, Zamboanga del Norte after having been duly sworn in
accordance with law, hereby depose and state:

That I am a holder and possessor of Automated Teller Machine(ATM) card

with Account Number 0516339713 issued by Land Bank of the Philippines-
Dipolog City Branch;

That on December 22, 2023, I discovered that my said ATM card was lost;
That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
ATM card.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day

of_____2023, at Dipolog City.

ALLEN FRANS T. QUISEL

(Affiant)
MSU IIT Iligan City School ID#2020-0501
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at

Dipolog City.

Doc. No.

Page No.

Book No.

Series of 2023

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ALEMAR T. SUMABANG, of legal age, Filipino, single, a resident of San Jose,

Dipolog City, after having been duly sworn in accordance with law, hereby
depose and state:

That I am holder and possessor of a Certificate of Registration of motor vehicle

with Engine No.K8910E007340 and Chassis No. K8910007362, Make: Honda, CR
No.294023015 and its Official Receipt(OR) issued by Land Transportation
Office(LTO);

That recently, I discovered that said Certificate of Registration and OR were lost,
and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it
as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
statements and for the purpose of attesting to the loss of the said Certificate of
Registration and OR issued by LTO.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

_______ 202__, at Dipolog City.

ALEMAR T. SUMABANG
(Affiant)
Driver’s License#N03-15-020207
With photo

SUBSCRIBED AND SWORN to before me this ___ day of ________ 202__, at Dipolog
City.

DOC.NO.

PAGE NO.

BOOK NO.

SERIES OF 2023

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x
 AFFIDAVIT OF LOSS

I, JEFREY TOMALA OGOC, of legal age, Filipino, married, a resident of Purok

Parpagayo,Minaog, Dipolog City, after having been duly sworn in accordance with
law, hereby depose and state:

That I am holder and possessor of a Certificate of Registration of motor vehicle

with plate number JW 5966, Make:Suzuki nd its Official Receipt(OR) issued by
Land Transportation Office(LTO);

That recently, I discovered that said Certificate of Registration and OR were lost,
and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it
as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
statements and for the purpose of attesting to the loss of the said Certificate of
Registration and OR issued by LTO.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

_______ 202__, at Dipolog City.

JEFREY TOMALA OGOC

(Affiant)
SSS ID#10-0560759-1
With photo

SUBSCRIBED AND SWORN to before me this ___ day of ________ 202__, at Dipolog
City.

DOC.NO.

PAGE NO.

BOOK NO.

SERIES OF 2023
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, RENATO PACULBA PINGKIAN, of legal age, Filipino, married, a resident of

Minaog, Dipolog City, after having been duly sworn in accordance with law,
hereby depose and state:

That I am holder and possessor of a Certificate of Registration of motor vehicle

with plate number 8675 JH and its Official Receipt(OR) issued by Land
Transportation Office(LTO);

That recently, I discovered that said Certificate of Registration and OR were lost,
and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it
as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
statements and for the purpose of attesting to the loss of the said Certificate of
Registration and OR issued by LTO.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

_______ 202__, at Dipolog City.

RENATO PACULBA PINGKIAN

(Affiant)
UMID ID#CRN-006-0069-1450-5
With photo

SUBSCRIBED AND SWORN to before me this ___ day of ________ 202__, at Dipolog
City.

DOC.NO.

PAGE NO.

BOOK NO.

SERIES OF 2023
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, EDEN IBONA CABUEÑOS, of legal age, Filipino, single, a resident of Isis,

Polanco, Zamboanga del Norte after having been duly sworn in accordance
with law, hereby depose and state:

That I was a holder and possessor of a Philippine Passport issued by the

Department of Foreign Affairs;

That recently, I discovered that my passport is lost;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
passport.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2023, at Dipolog City.

EDEN IBONA CABUEÑOS

(Affiant)
VIN#72100037BK2689EIC20000-4
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at

Dipolog City.

Doc. No.___

Page No.___

Book No.___
Series of 2023

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, EDEN M. PAGENTE, Filipino, of legal age, widow, and a resident of Purok

Parpagayo, Olingan Dipolog City, Zamboanga del Norte after having been
duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of a receipt with number 0565-2022-

01492 issued by MLhuillier for a pawned jewelry identified as Necklace YG
Def 2.00 grams and Pendant YG Def 1.3 grams in the amount of P7,500.00
pawned on August 26,2022;

That recently, I found out that my receipt was lost, I tried to locate the
receipt but it was really lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
receipt.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2023, at Dipolog City.

EDEN M. PAGENTE
(Affiant)
Deped Employee ID#4909883
With phot

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at

Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2023

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, LYNYRD DAGAYLOAN LUAGUE, of legal age, Filipino, single, a resident of 83

Mango Green Village, Banilad, Mandaue City, after having been duly sworn in
accordance with law, hereby depose and state:

That I am holder and possessor of a Driver’s License and its Official Receipt(OR)
issued by Land Transportation Office(LTO);

That recently, I discovered that said Driver’s License and OR were lost, and could
not be found;

That despite effort to recover the same but it was naught. Hence, I considered it
as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
statements and for the purpose of attesting to the loss of the said Driver’s license
and OR issued by LTO.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

_______ 202__, at Dipolog City.

LYNYRD DAGAYLOAN LUAGUE

(Affiant)
Philippine Passport#P7856014B
With photo

SUBSCRIBED AND SWORN to before me this ___ day of ________ 202__, at Dipolog
City.
DOC.NO.

PAGE NO.

BOOK NO.

SERIES OF 2023

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, MELCOLYN SON, of legal age, Filipino, single, a resident of Silawe, Polanco,

Zamboanga del Norte after having been duly sworn in accordance with law,
hereby depose and state:

That I am holder and possessor of a Passbook issued by Katipunan Bank with

account number 021221174394;

That recently, I discovered that said passbook was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it
as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
statements and for the purpose of attesting to the loss of the said passbook.
IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of
_______ 202__, at Dipolog City.

MELCOLYN SON
(Affiant)
Valid ID#___________
With photo

SUBSCRIBED AND SWORN to before me this ___ day of ________ 202__, at Dipolog
City.

DOC.NO.

PAGE NO.

BOOK NO.

SERIES OF 2023

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, LHEXTER BARTONICO ODATO, of legal age, Filipino, married, a resident of

Miputak, Dipolog city, Zamboanga del Norte after having been duly sworn in
accordance with law, hereby depose and state:

That I am holder and possessor of a Certificate of Registration(CR) of a motor

vehicle with CR No.40119146 and its Official Receipt(OR) with number
2169871034 issued by Land Transportation Office(LTO);

That recently, I discovered that said CR and OR were lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it
as totally lost;
As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
statements and for the purpose of attesting to the loss of the said CR and OR
issued by LTO.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

_______ 202__, at Dipolog City.

LHEXTER BARTONICO ODATO

(Affiant)
Driver’s License#J07-18-004911
With photo

SUBSCRIBED AND SWORN to before me this ___ day of ________ 202__, at Dipolog
City.

DOC.NO.

PAGE NO.

BOOK NO.

SERIES OF 2023

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, DONNA M. BAYAWA, of legal age, Filipino, married, a resident of Galas, Dipolog

city, Zamboanga del Norte after having been duly sworn in accordance with law,
hereby depose and state:

That I am holder and possessor of a Driver’s License with number J01-82-008740

and its Official Receipt(OR) issued by Land Transportation Office(LTO);

That recently, I discovered that said Driver’s License and OR were lost, and could
not be found;

That despite effort to recover the same but it was naught. Hence, I considered it
as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
statements and for the purpose of attesting to the loss of the said Driver’s license
and OR issued by LTO.
IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of
_______ 202__, at Dipolog City.

DONNA M. BAYAWA
(Affiant)
OSCA ID#9001-issued in Dipolog City
With photo

SUBSCRIBED AND SWORN to before me this ___ day of ________ 202__, at Dipolog
City.

DOC.NO.

PAGE NO.

BOOK NO.

SERIES OF 2023
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, SUNNY O. ZAPANTA, of legal age, Filipino, married, a resident of

Sta.Filomena, Dipolog City, Zamboanga del Norte, after having been duly
sworn in accordance with law, hereby depose and state:

That I am the keeper of the Business Permit and Business Plate of MON-
STAR AUTO SPARE PARTS AND REPAINTING SHOP, located at Highway,
Turno, Dipolog City, registered under my name;

That recently, while I was trying to look for the said business permit and
plate from where I kept it, I found out that the business plate and permit
were lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost;

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

foregoing statements and for the purpose of attesting to the loss of the said
business permit and plate.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2023, at Dipolog City.

SUNNY O. ZAPANTA
(Affiant)
Driver’s License#J01-00-033848
 With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at

Dipolog City.

Doc No. _____

Page No. _____
Book No. ____
Series of 2023

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, CAROL LYN ZAMORA DARASIN, of legal age, Filipino, single, a resident of

Purok 2, Poblacion, La Libertad Zamboanga del Norte after having been
duly sworn in accordance with law, hereby depose and state:

That I was a holder and possessor of a Philippine Passport issued by the

Department of Foreign Affairs;

That on January 9, 2023, while I was traveling from Dipolog City to la

Libertad I discovered that my passport is lost;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
passport.
IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of
__________ 2023, at Dipolog City.

CAROL LYN ZAMORA DARASIN

(Affiant)
Driver’s License#J01-15-003762 valid until 2031/12/26
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at

Dipolog City.

Doc. No.___

Page No.___

Book No.___

Series of 2023
IVO M. MANDANTES, CPA

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, MARK S. SERIPA, of legal age, Filipino, married, a resident of Brgy.

Larayan, Dapitan City, Zamboanga del Norte after having been duly sworn
in accordance with law, hereby depose and state:

That I am a holder and possessor of Automated Teller Machine(ATM) card

with Account Number 3806629048 issued by Land Bank of the Philippines-
Dapitan City Branch;

That recently, I discovered that my said ATM card was lost;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.
As such, I am executing this Affidavit of Loss to attest to the truth of the
foregoing statements and for the purpose of attesting to the loss of the said
ATM card.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day

of_____2023, at Dipolog City.

MARK S. SERIPA
(Affiant)
Driver’s License#J01-19-002348
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at

Dipolog City.

Doc. No.

Page No.

Book No.

Series of 2023

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, CRISTY BACABIS SUREM, of legal age, Filipino, single, a resident of Kauswagan,Baliguian, Zamboanga
del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of a Tax Identification Number(TIN) card issued by the Bureau of
Internal Revenue.

That recently, while I was trying to look for my said TIN card, then I found out that it was lost, and
could not be found;
That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said TIN card.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of ______ 2023, at Dipolog
City.

CRISTY BACABIS SUREM

(Affiant)
PRC ID#1920652
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at Dipolog City.

Doc. No.
Page No.
Book No.
Series of 2023

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF NON-LOSS

I, CONCEPCION T. MILALLOS, of legal age, Filipino, widow, resident of Anahaw, Galas,

Dipolog City, Zamboanga del Norte after having been duly sworn in accordance with law,
hereby depose and state:

That I am the owner of a parcel of land, more particularly described as follows:

“A parcel of land known as Lot 1611-F-4, Psd-09-066946 situated at Galas, Dipolog City
containing an area of six hundred nine(609) square meters covered by Transfer Certificate of
Title No.T-35766 issued by the Register of Deeds for Dipolog City and Tax Declaration
No.2021-03-0008-00564.”

That I have possession of owner’s duplicate copy of the said parcel of land’s certificate of title.

As such, I am executing this Affidavit of Non-Loss to attest to the truth of the foregoing
statements and for the purpose of annotating this document before the Register of Deeds of
Dipolog City and certifying the non-loss of said certificate of title.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________
2023, at Dipolog City.

CONCEPCION T. MILALLOS

(Affiant)

OSCA ID#3988-Dipolog City

With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at Dipolog City.

DOC. NO. DARIO M. MANDANTES

PAGE NO. Notary Public for Dipolog City, Dapitan City
BOOK NO. and Zamboanga del Norte
SERIES OF 2023 Attorney’s Roll No.51545
Commission No.036-2022
PTR No.2625307-1/3/2023
Valid until 12/31/2024

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, LYNDELL JUSTINE D. CONTIOSO, of legal age, Filipino, single, a resident of Purok Bougainvilla, Sta.
Filomena, Dipolog City after having been duly sworn in accordance with law, hereby depose and
state:

That I am a holder and possessor of a School Identification(ID) Card issued by my school Dipolog
Medical Center College Foundation, Inc., Dipolog City for being its student.
That recently, while I was trying to look for my said school ID, then I found out that my school ID was
lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said School ID.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of ______ 2023, at Dipolog
City.

LYNDELL JUSTINE D. CONTIOSO

(Affiant)
Philhealth ID#14-250036512-8
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2023, at Dipolog City.

Doc. No.
Page No.
Book No.
Series of 2023

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS
I, DULCITA S. DIAMANTE, of legal age, Filipino, married, a resident of Biasong, Dipolog City after
having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of a receipt for RL EPEB No.2022002507 issued by Register of Deeds
for Zamboanga del Norte for the annotation on the title of parcel of land I inherited.

That recently, while I was trying to look for my said receipt from my file folder, then I found out that
my receipt was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said receipt and reissuance of the same and claiming the
documents anent to the receipt.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of ______ 202_, at Dipolog
City.

DULCITA S. DIAMANTE
(Affiant)
UMID ID#CRN-006-0077-6122-3
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 202_, at Dipolog City.

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x
 AFFIDAVIT OF LOSS

I, BRYAN Q. LILAGAN, of legal age, Filipino, single, a resident of Purok Tunggo,

Minaog, Dipolog city, Zamboanga del Norte after having been duly sworn in
accordance with law, hereby depose and state:

That I am holder and possessor of a Driver’s License and its Official Receipt(OR)
issued by Land Transportation Office(LTO);

That recently, I discovered that said Driver’s License and OR were lost, and could
not be found;

That despite effort to recover the same but it was naught. Hence, I considered it
as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
statements and for the purpose of attesting to the loss of the said Driver’s license
and OR issued by LTO.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

_______ 202__, at Dipolog City.

BRYAN Q. LILAGAN
(Affiant)
Driver’s License#N26-19-025758
With photo

SUBSCRIBED AND SWORN to before me this ___ day of ________ 202__, at Dipolog
City.

DOC.NO.

PAGE NO.

BOOK NO.

SERIES OF 202___
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, EDEN M. PAGENTE, Filipino, of legal age, widow, and a resident of Purok

Parpagayo, Olingan Dipolog City, Zamboanga del Norte after having been
duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of a receipt with number 0565-2022-

01492 issued by MLhuillier for a pawned jewelry identified as Necklace YG
Def 2.00 grams and Pendant YG Def 1.3 grams in the amount of P7,500.00
pawned on August 26,2022;

That recently, I found out that my receipt was lost, I tried to locate the
receipt but it was really lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
receipt.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2022, at Dipolog City.

EDEN M. PAGENTE
(Affiant)
Deped Employee ID#4909883
With phot

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2022, at

Dipolog City.

Doc. No.__
Page No.__
Book No.__
Series of 2022
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, MEDINA D. ACENAS, Filipino, of legal age, married, and a resident of Brgy.

Sicayab, Dipolog City, Zamboanga del Norte after having been duly sworn
in accordance with law, hereby depose and state:

That I am a holder and possessor of receipt number 0724-2022-01062

issued by MLhuillier for a pawned jewelry identified as yg Ring def 18k .9
Grams in the amount of P2,350.00 pawned on October 28,2022.

That recently, I found out that my said receipt was lost, I tried to locate the
receipt but it was really lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
receipt of MLhuillier.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2022, at Dipolog City.

MEDINA D. ACENAS
(Affiant)
Phil.Post ID#PRNM83200024480P
With phot

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2022, at

Dipolog City.

Doc. No.__
Page No.__
Book No.__
Series of 2022
J

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF TRANSFER/WAIVER

I, RONALD JESON P. NADORRA, of legal age, Filipino, married , resident of

Magsaysay St., Miputak, Dipolog city, hereby state under oath:

That I am a permittee of a building permit with Number 2210-4055-B dated

10/10/2022, FSEC No.R22022-09-064 dated 10/03/2022 issued by Office of
Building Official of Katipunan, Zamboanga del Norte;

That I hereby transfer and waive the the building permit and the building
itself issued under my name in favor of BLESSED KING P. HISARZA, of legal
age, Filipino, single, resident of Miputak, Dipolog City.

That Blessed King P. Hisarza is the actual owner over the said building,
parcel of land it is situated and the permit issued under my name.

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

statements.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2022, at Dipolog City.

RONAlD JESON P. NADORRA

(Affiant)
Driver’s License#J01-06-002649
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2022, at

Dipolog City.

Doc. No.___

Page No.___

Book No.___

Series of 2022
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF DISCREPANCY

I, FRANZ O. TRIAMBULO, of legal age, Filipino, married, a resident of 741

Upper Turno, Dipolog City Zamboanga del Norte after having been duly
sworn in accordance with law, hereby depose and state:

That I am the owner of a motor vehicle with the following details:

Make:FUSO PLATE NO.JAN1874

ENGINE NO.:8DC90525144 CHASSIS NO.:FS54VZ-502001

CR NO.0003876194 BODY TYPE:TRUCK SELF LOADING W/ BOOM

TRUCK

COLOR:ORANGE VEHICLE TYPE:TRUCK/BUS

That there is a typographical error in the Certificate of Registration in the

said motor vehicle because it appeared that the Chassis Number is FSS4V7-
502001;

That the true and correct Chassis Number is FS54VZ-502001;

That the discrepancy appeared between letter “S” and number “5”, and
letter “Z” and number “7”, respectively only which appeared similar;

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

statements.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2022, at Dipolog City.

FRANZ O. TRIAMBULO
(Affiant)
Valid ID#______________
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2022, at

Dipolog City.

Doc. No.___

Page No.___

Book No.___
Series of 2022

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, RUSSELL C. DETABLAN, of legal age, Filipino, married, a resident of Turno,

Dipolog City Zamboanga del Norte after having been duly sworn in
accordance with law, hereby depose and state:

That I was a holder and possessor of a Philippine Passport issued by the

Department of Foreign Affairs;

That recently, I discovered that my passport is lost;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
passport.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2022, at Dipolog City.

RUSSELL C. DETABLAN
(Affiant)
Driver’s License#J04-17-003108 valid until 2031/12/11
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2022, at

Dipolog City.

Doc. No.___
Page No.___

Book No.___

Series of 2022

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ESTRELLITA E. JARMIN, of legal age, Filipino, single/married, a resident of

Brgy. Sta.Filomena, Dipolog City, Zamboanga del Norte after having been
duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of Automated Teller Machine(ATM) card

issued by Land Bank of the Philippines-Dipolog City Branch;

That recently, I discovered that my said ATM card was lost;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
ATM card.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2021, at Dipolog City.

ESTRELLITA E. JARMIN
(Affiant)
PRC ID#0673231 until 3/2/2025-Professional Teacher
With photo
SUBSCRIBED AND SWORN to before me this ___ day of _________ 2022, at
Dipolog City.

Doc. No.

Page No.

Book No.

Series of 2022

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, EUTIQUIO ELUMBARING, of legal age, Filipino, a resident of Sipaloc, Sibutad,

Zamboanga del Norte after having been duly sworn in accordance with law,
hereby depose and state:

That I was a holder and possessor of a sepia copy, and other copies of blueprint of
Approved Subdivision Plan PSD-09-062620 for parcel of land covered by TCT No.T-
20610, Lot No.604-A, situated at Sipaloc, Sibutad, Zamboanga del Norte.

That recently while I was checking my file containing the said documents so that I
could process titling over said land, I found out that the documents were lost, and
could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it
as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
statements and for the purpose of attesting to the loss of the said sepia copy, 4
copies of blueprint, and technical descriptions documents and request for
replacement of the same.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2022, at Dipolog City.
EUTIQUIO ELUMBARING

(Affiant)

Valid ID#________________

With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2022, at Dipolog
City.

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ROJARD GEBONE PANER, of legal age, Filipino, widower, a resident of Lingasad,

Polanco, Zamboanga del Norte after having been duly sworn in accordance with
law, hereby depose and state:

That I am the surviving spouse of ELENITA FAT PANER. That my late spouse while I
was working as seaman abroad;

That she was holder and possessor of following identification cards: Unified Multi-
purpose ID(UMID), Voter’s ID, and Person with Disability(PWD) ID;

That I left for abroad and when she died i tried to locate those documents but
those were lost and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it
as totally lost;
As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
statements and for the purpose of attesting to the loss of the said Unified Multi-
purpose ID(UMID), Voter’s ID, and Person with Disability(PWD).

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

December 2022, at Dipolog City.

ROJARD GEBONE PANER

(Affiant)
UMID ID#CRN-0111-0768145-7
With photo

SUBSCRIBED AND SWORN to before me this ___ day of December 2022, at Dipolog
City.

DOC.NO.

PAGE NO.

BOOK NO.

SERIES OF 2022

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, JUDIL MANDADO ALBOS, of legal age, Filipino, single, a resident of Lamao, Liloy,
Zamboanga del Norte after having been duly sworn in accordance with law,
hereby depose and state:

That I was holder and possessor of wallet containing cash of P10,000.00, Non-
Professional Driver’s License Identification Card(ID) issued by Land Transportation
Office(LTO), Philhealth ID, Tax Identification Number(TIN) ID, School ID, Copy of
OR/CR of motor vehicle Suzuki Raider with CR No.39998876-1/ and other papers;

That my wallet containing those documents was lost, and could not be found;
That despite effort to recover the same but it was naught. Hence, I considered it
as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
statements and for the purpose of attesting to the loss of the said cash of
P10,000.00, Non-Professional Driver’s License Identification Card(ID) issued by
Land Transportation Office(LTO), Philhealth ID, Tax Identification Number(TIN) ID,
School ID, Copy of OR/CR of motor vehicle Suzuki Raider and other papers.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

December 2022, at Dipolog City.

JUDIL MANDADO ALBOS

(Affiant)
SSS #35-0970998-0
With photo

SUBSCRIBED AND SWORN to before me this ___ day of December 2022, at Dipolog
City.

DOC.NO.

PAGE NO.

BOOK NO.

SERIES OF 2022

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, GHERLINE B. GUALDERAMA, of legal age, Filipino, single, a resident of Poblacion

North, Pinan, Zamboanga del Norte after having been duly sworn in accordance
with law, hereby depose and state:
That I am holder and possessor of a Student Permit- Driver’s License and its
Official Receipt(OR) issued by Land Transportation Office(LTO);

That recently, I discovered that said Student Permit-Driver’s License and OR were
lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it
as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
statements and for the purpose of attesting to the loss of the said Student Permit-
Driver’s license and OR issued by LTO.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

December 2022, at Dipolog City.

GHERLINE B. GUALDERAMA
(Affiant)
UMID ID#CRN-0111-0755984-8
With photo

SUBSCRIBED AND SWORN to before me this ___ day of December 2022, at Dipolog
City.

DOC.NO.

PAGE NO.

BOOK NO.

SERIES OF 2022

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, GEMAR C. LAURQUE, of legal age, Filipino, single/married, a resident of

Poblacion South,Polanco, Zamboanga del Norte after having been duly
sworn in accordance with law, hereby depose and state:

That I was a holder and possessor of a Certificate of Registration(CR) of

Motor vehicle and its Official Receipt(OR) described as :MAKE:Honda, CR No.
11818499-0, Engine No.:L13A-1094255,Chassis No.GDI-1085387, Series:Fit,
registered under the name of Princess Grace Arnoco. That the vehicle was
bought by my sibling;

That recently, I found out that my CR was lost;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
CR.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2022, at Dipolog City.

GEMAR C. LAURQUE
(Affiant)
DL#J07-20-007102
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2022, at

Dipolog City.

Doc. No.___

Page No.___

Book No.___

Series of 2022

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, FLORICHELLE ESTOCONING GERAGA, of legal age, Filipino, single, a resident of Bago,

Sindangan, Zamboanga del Norte after having been duly sworn in accordance with law,
hereby depose and state:

That I am a holder/possessor of receipt of pawned jewelry issued by Cebuana Lhuillier

Pawnshop Sindangan, ZN Branch with Ticket No.60809SG025496;

That recently, while I was trying to locate the said receipt I could not find it because it was lost
and could not be found;
That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements
and for the purpose of attesting to the loss of the said receipt.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2022,
at Dipolog City.

FLORICHELLE ESTOCONING GERAGA

(Affiant)
UMID ID#CRN-0111-9006802-9

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2022, at Dipolog City.

Doc. No.

Page No.

Book No.

Series of 2022

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, BELTRAN A. DALIDA, of legal age, Filipino, married, resident of Milad, Polanco, Zamboanga del Norte
after having been duly sworn in accordance with law, hereby depose and state:
That I am the holder and possessor of owner’s copy of certificate of title for parcel of land which I owned.

That the said parcel of land is known as:

“A parcel of land known as Lot 7, CCS-09-08-000048, situated at Milad, Polanco, Zamboanga del Norte
containing an area of 16,114 square meters covered by Original Certificate of Title No.P-28972.”

That I have lost the owner’s copy of said parcel of land ;

That despite effort to recover the same but it was naught.

That I considered it as totally lost.

That I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for the purpose
of attesting to the loss of the said owner’s copy of Original Certificate of Title No.P-28972.

IN WITNESS WHEREOF, I have hereunto affixed my signature this __th day of _______ 2022, at Dipolog
City.

BELTRAN A. DALIDA

(Affiant)

Voters ID#7201-0131A-J2568JRE20001-5

SUBSCRIBED AND SWORN to before me this ___th day of ________ 2022, at Dipolog City.

DOC.NO. ______

PAGE NO.___

BOOK NO.___

SERIES OF 2022
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF CIVIL STATUS

We: MARY ANGELI O. NECESARIO, RAHJICK P. NECESARIO and MITCH P.

NECESARIO,all of legal age,all Filipinos, all single, all residents of Opao,
Dapitan City, Zamboanga del Norte after having been duly sworn in
accordance with law, hereby depose and state:

That we have all civil staus of “SINGLE”.

That we are executing this Affidavit attest to the truth of the foregoing
statements.

IN WITNESS WHEREOF, we have hereunto affixed our signatures this ___ day
of __________ 2022, at Dipolog City.

MARY ANGELI P. NECESARIO

(Affiant)
Valid ID#___________________
With photo

RAHJICK P. NECESARIO
(Affiant)
Valid ID#_________________________
With photo

MITCH P. NECESARIO
(Affiant)
Valid ID#________________________
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2022, at

Dipolog City.

Doc. No.___

Page No.___

Book No.___

Series of 2022
MARIAFIEL DALIDA-ISAGAN

Affiant

OSCA ID#22788-Las Pinas City, Manila

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, MARY JOYCE NALZARO MONTES, of legal age, Filipino, married, a resident

of Gulayon, Dipolog City, Zamboanga del Norte after having been duly
sworn in accordance with law, hereby depose and state:

That I was a holder and possessor of Official Receipts(OR) issued by Imperial

Appliance Plaza for purchased Television with Numbers 19328 dated
5/27/22 and 171308 dated 10/26/22;

That recently, I found out that my ORs were lost;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
ORs.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2022, at Dipolog City.

MARY JOYCE NALZARO MONTES

(Affiant)
Umid ID#CRN-021-1830-3609-7
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2022, at

Dipolog City.

Doc. No.___
Page No.___

Book No.___

Series of 2022

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF NON-RECEIPT OF CHECK

I, PABLO ARCALA TUBIGON, JR, of legal age, Filipino, single/married, a

resident of 030-B Rizal Ave Ext Cor. Lapu-lapu St, Estaka, Dipolog City,
Zamboanga del Norte after having been duly sworn in accordance with law,
hereby depose and state:

That I was an applicant for educational loan at the Social Security

System(SSS) in March 2022;

That I have been waiting for a long period of time for the release of the
check of my loan however I was informed that a check was issued already.
The check has a number 4968387;

That I have not received the check of the educational loan I applied for nor
encashed it;

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

statements.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2022, at Dipolog City.

PABLO A. TUBIGON,JR
(Affiant)
SSS #33-48986456
With photo
SUBSCRIBED AND SWORN to before me this ___ day of _________ 2022, at
Dipolog City.

Doc. No.___

Page No.___

Book No.___

Series of 2022

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF NON-RECEIPT OF CHECK

I, JOSE EDEN M. ESMERALDA, of legal age, Filipino, married, a resident of

030-B Rizal Ave Ext Cor. Lapu-lapu St, Estaka, Dipolog City, Zamboanga del
Norte after having been duly sworn in accordance with law, hereby depose
and state:

That I was an applicant for educational loan at the Social Security

System(SSS) in February 2022;

That I have been waiting for a long period of time for the release of the
check of my loan however I was informed that a check was issued already.
The check has a number 4967565;

That I have not received the check of the educational loan I applied for nor
encashed it;

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

statements.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2022, at Dipolog City.
 JOSE EDEN M. ESMERALDA
(Affiant)
SSS #33-16071283
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2022, at

Dipolog City.

Doc. No.___

Page No.___

Book No.___

Series of 2022

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, GENELYN S. BAUL, of legal age, Filipino, single/married, a resident of

Poblacion,Sibutad, Zamboanga del Norte after having been duly sworn in
accordance with law, hereby depose and state:

That I was a holder and possessor of a Certificate of Registration(CR) of

Motor vehicle and its Official Receipt(OR) described as :MAKE:Yamaha, CR
No.282815433, Engine No.:E3R2E-1413051,Chassis
No.PAOSE9810H0142895, Series:Mio I 125 BB34, registered under my late
sibling Raymond B.Sarita;

That recently, I found out that my CR and OR was lost;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
CR and OR.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2022, at Dipolog City.

GENELYN S. BAUL
(Affiant)
 Solo Parent ID#SIBSP22-029-Sibutad,ZN
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2022, at

Dipolog City.

Doc. No.___

Page No.___

Book No.___

Series of 2022

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, GENELYN S. BAUL, of legal age, Filipino, single/married, a resident of

Poblacion,Sibutad, Zamboanga del Norte after having been duly sworn in
accordance with law, hereby depose and state:

That I was a holder and possessor of a Certificate of Registration(CR) of

Motor vehicle and its Official Receipt(OR) described as :MAKE:Yamaha, CR
No.282815433, Engine No.:E3R2E-1413051,Chassis
No.PAOSE9810H0142895, Series:Mio I 125 BB34, registered under my late
sibling Raymond B.Sarita;

That recently, I found out that my CR and OR was lost;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
CR and OR.
IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of
__________ 2022, at Dipolog City.

GENELYN S. BAUL
(Affiant)
Solo Parent ID#SIBSP22-029-Sibutad,ZN
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2022, at

Dipolog City.

Doc. No.___

Page No.___

Book No.___

Series of 2022

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, LEONIDES B. SUMINGUIT, of legal age, Filipino, married, a resident of Turno,

Dipolog City, Zamboanga del Norte after having been duly sworn in accordance
with law, hereby depose and state:

That I was a holder and possessor of a sepia copy, 4 copies of blueprint and
corresponding Technical Descriptions of Approved Subdivision Plan PSD-09-
066059 for parcel of land covered by TCT No.T-32783, Lot No.728-E, situated at
Turno, Dipolog City, Zamboanga del Norte.

That recently while I was checking my file containing the said documents so that I
could process titling over said land, I found out that the documents were lost, and
could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it
as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
statements and for the purpose of attesting to the loss of the said sepia copy, 4
copies of blueprint, and technical descriptions documents and request for
replacement of the same.
IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of
__________ 2022, at Dipolog City.

LEONIDES B. SUMIGUIT

(Affiant)

OSCA ID#SIB-14-1129-Sibutad,ZN

With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2022, at Dipolog
City.
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ANGELINA R. CAIDET, of legal age, Filipino, widow, a resident of San Antonio,

Polanco, Zamboanga del Norte after having been duly sworn in accordance with
law, hereby depose and state:

That I am holder and possessor of electronic Certificate Authorizing

Registrationd(eCARs) of transfer taxes and its receipts issued by the Bureau of
Internal Revenue for the parcels of land covered by Transfer Certificate of
Title(TCT) No.T-40641 and TCT No.T-67884, situated at San Antonio and Lingasad,
respectively, Polanco, Zamboanga del Norte;

That in recently, I discovered that said documents were lost, and could not be
found;

That despite effort to recover the same but it was naught. Hence, I considered it
as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
statements and for the purpose of attesting to the loss of the said eCARs.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

November 2022, at Dipolog City.

ANGELINA R. CAIDET
(Affiant)
OSCA ID#18-01591 -Polanco,ZN
With photo

SUBSCRIBED AND SWORN to before me this ___ day of November 2022, at Dipolog
City.

DOC.NO.

PAGE NO.

BOOK NO.

SERIES OF 2022
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, JOHN DEAN B. MENDOZA, of legal age, Filipino, married, a resident of Estaka,

Dipolog City, Zamboanga del Norte after having been duly sworn in accordance
with law, hereby depose and state:

That I am holder and possessor of a Driver’s License and its Official Receipt(OR)
issued by Land Transportation Office(LTO);

That recently, I discovered that said Driver’s License and OR were lost, and could
not be found;

That despite effort to recover the same but it was naught. Hence, I considered it
as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
statements and for the purpose of attesting to the loss of the said driver’s license
and OR issued by LTO.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

November 2022, at Dipolog City.

JOHN DEAN B. MENDOZA

(Affiant)
TIN#422-664-731
With photo

SUBSCRIBED AND SWORN to before me this ___ day of November 2022, at Dipolog
City.

DOC.NO.

PAGE NO.

BOOK NO.

SERIES OF 2022
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, JUDELYN R. ENTERO, of legal age, Filipino, married, resident of Polo, Dapitan City, Zamboanga del Norte
after having been duly sworn in accordance with law, hereby depose and state:

That I am the holder and possessor of claim slip

That my principal had lost the said owner’s copy of said parcel of land ;

That despite effort to recover the same but it was naught.

That I/he considered it as totally lost.

That I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for the purpose
of attesting to the loss of the said owner’s copy of Original Certificate of Title No.P-12921.

IN WITNESS WHEREOF, I have hereunto affixed my signature this __th day of _______ 2022, at Dipolog
City.

JUDELYN R. ENTERO

(Affiant)

Voters ID#7201-0131A-J2568JRE20001-5
SUBSCRIBED AND SWORN to before me this ___th day of ________ 2022, at Dipolog City.

DOC.NO. ______

PAGE NO.___

BOOK NO.___

SERIES OF 2022

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, JENNELYN MANZANO RESURRECCION, of legal age, Filipino, married, a

resident of San Antonio, Polanco, Zamboanga del Norte after having been
duly sworn in accordance with law, hereby depose and state:

That I was a holder and possessor of a Philippine Passport issued by the

Department of Foreign Affairs;

That on November 14, 2022, I found out that my said passport was missing
after it fell out from my bag while I traveled from Dapitan City to my house
at Polanco, Zamboanga del Norte;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
passport.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2022, at Dipolog City.

JENNELYN MANZANO RESURRECION

(Affiant)
 VIN#6511-0113A=E2587JMR20000
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2022, at

Dipolog City.

Doc. No.___

Page No.___

Book No.___

Series of 2022

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ARACELI F. NECESARIO, of legal age, Filipino, a resident of Mabini St., Barra, Dipolog City,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am the holder and possessor of an original copy of BIR Tax Payment Deposit Slip and Capital
Gains Tax Return on sale of parcel of land covered by OCT No.P-1022 and its eCARs issued by the
Bureau Internal Revenue.

That I discovered that above-mentioned documents were lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said BIR Tax Payment Deposit Slip and Capital Gains Tax
Return on sale of parcel of land covered by OCT No.P-1022 and its eCARs issued by the Bureau
Internal Revenue

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2022, at
Dipolog City.

ARACELI F. NECESARIO
 (Affiant)
Driver’s License#N03-89-083880
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2022, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2022

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, RONALD JESON P. NADORRA, of legal age, Filipino, single, a resident of Magsaysay St., Miputak,
Dipolog City, Zamboanga del Norte after having been duly sworn in accordance with law, hereby
depose and state:

That I am the holder and possessor of approved survey plan and technical description of Lot 1377
under parcel of land covered by TCT No.T-31763 situated at Gulayon, Dipolog City.

That I kept the Approved Survey and it attachements but those were lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said Approved Survey and Technical Descriptions.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2022, at
Dipolog City.
 RONALD JESON P. NADORRA
(Affiant)
Driver’s License#J01-06-002649
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2022, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2022

That it is because the original copy was lost;

That I hereby certify that both original copy and photocopy of the deed of sale represent the
same content and texts;

As such, I am executing this Affidavit to attest to the truth of the foregoing statements and for
other legal purposes it may serve.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2020,
at Dipolog City.

ARNOLD B. BERMUDEZ
(Affiant)
SSS ID#10-0402846-9
With photo
SUBSCRIBED AND SWORN to before me this ___ day of _________ 2020, at Dipolog City.

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, GEVA C. ELUMBARING, of legal age, Filipino, married, a resident of Poblacion,

Sibutad, Zamboanga del Norte after having been duly sworn in accordance with
law, hereby depose and state:

That I am holder and possessor of a Driver’s License and its Official Receipt(OR)
issued by Land Transportation Office(LTO);

That recently, I discovered that said Driver’s License and OR were lost, and could
not be found;

That despite effort to recover the same but it was naught. Hence, I considered it
as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
statements and for the purpose of attesting to the loss of the said driver’s license
and OR issued by LTO.
IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of
November 2022, at Dipolog City.

GEVA C. ELUMBARING
(Affiant)
Phil.Passport#P9092890A until 09-Oct-2028
With photo

SUBSCRIBED AND SWORN to before me this ___ day of November 2022, at Dipolog
City.

DOC.NO.

PAGE NO.

BOOK NO.

SERIES OF 2022

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, MARICOR MARAGUINOT DIMASUHID, of legal age, Filipino, single, a resident of Olingan, Dipolog
City, Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and
state:

That I am holder and possessor of my High School Diploma Batch 2002-2003 as a graduate issued by
Alberto Q. Ubay Memorial Agro Tech Science High School;

That I discovered that the original copy of my Diploma was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;
As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said Diploma.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2022, at
Dipolog City.

MARICOR M. DIMASUHID
(Affiant)
Phil. Passport #P8632630A valid until 5 September 2028
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2022, at Dipolog City.

Doc. No.

Page No.

Book No.

Series of 2022

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, JEMVIE S. MACAPONDAG, of legal age, Filipino, a resident of San Isidro, Gutalac, Zamboanga del
Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am holder and possessor of a Driver’s License card with number M02-17-003041 issued by LTO
and UMID ID card with number CRN-0111-1187771-0

That I discovered that my cards were lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said cards.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2022, at
Dipolog City.
 JEMVIE S. MACAPONDAG
(Affiant)
Driver’s License#M02-17-003041
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2022, at Dipolog City.

Doc. No.

Page No.

Book No.

Series of 2022

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ESTEBAN P. GUMELA, of legal age, Filipino, widower, a resident of Turno, Dipolog City, Zamboanga
del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am holder and possessor of an original copies of estate tax returns of Ma. Luz Fredesvienda B.
Gumela, as well as the eCAR, tax payments and receipts and other BIR related documents of said
estate

That I discovered that my documents were lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said documents.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2022, at
Dipolog City.

ESTEBAN P. GUMELA
(Affiant)
TIN# 271-925-959
 With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2022, at Dipolog City.

Doc. No.

Page No.

Book No.

Series of 2022

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, RUBEN P. ANCERO, of legal age, Filipino, married to Joselita Ancero, a resident of Minaog, Dipolog
City, Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and
state:

That I am holder and possessor of a BIR Stamped Extrajudicial Partiton with Simultaneous Sale and
Affidavit of Publication of said Extrajudicial Partition with Simultanenous Sale notarized by Jonald C.
Napigquit per Doc. No.3532, Page No. 69, Book No. 70, Series of 2019 with its clippings issued by a
local newspaper;

That I discovered that my document and affidavit with clippings was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said document and affidavit with clippings.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2022, at
Dipolog City.

RUBEN P. ANCERO
(Affiant)
ID#____________
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2022, at Dipolog City.

Doc. No.

Page No.
Book No.

Series of 2022

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, FELY REDOBLE PASTER, of legal age, Filipino, single, a resident of Marapong, Sergio Osmena,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am holder and possessor of a Professional Regulation Commission(PRC) Identification card as

Professional Teacher;

That I discovered that my PRC license was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said PRC license.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2022, at
Dipolog City.
 FELY REDOBLE PASTER
(Affiant)
Philhealth ID#14-201684359-7
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2022, at Dipolog City.

Doc. No.

Page No.

Book No.

Series of 2022

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ELSA A. SILAO, of legal age, Filipino, married, a resident of Turno, Dipolog City, Zamboanga del Norte
after having been duly sworn in accordance with law, hereby depose and state:

That I am representative of Chona M. Pandong, one of the purchasers of parcel of land as evidence by
Deed of Sale of a Portion of a Real Estate notarized by Atty. Eulogio L. Lagudas,Jr per Doc. No.2998,
Page No.18, Book No.20, Series of 2014;

That the said original deed with BIR stamp including the eCARs and other related documents were
endorsed to me by Chona M. Pandong. That however those document were lost.

That I tried to locate the said documents, but it could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;
As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said BIR stamped Deed of Absolute Sale, eCAR and other
related documents.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2022, at
Dipolog City.

ELSA A. SILAO
(Affiant)
ID#________________________
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2022, at Dipolog City.

Doc. No.

Page No

Book No

Series of 2022

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT

I, GLORIA BALUMA, of legal age, Filipino, married to Perfecto Potot, a resident of

Egot, Estaka, Dipolog City, Zamboanga del Norte after having been duly sworn in
accordance with law, hereby depose and state:

That I am the seller of a portion of parcel of land known as Lot 1844-A-2-D,Psd-09-

078234 covered by Transfer Certificate of Title No.128-20190000936 situated at
Gulayon, Dipolog City issued by the Register of Deeds for Dipolog City;

That the deeds were notarized by Atty Jeneth Napigquit Baje per Doc. No.3900,
Page No.28, Book No.198, Series of 2019 and Doc. No.4033, Page No.55, Book
No.198, Series of 2020;

That the said deeds executed do not include sale on the legal easement of right of
way of 20-meter wide;

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

statements.
IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of
October 2022, at Dipolog City.

GLORIA BALUMA
(Affiant)
OSCA ID#2087-Dipolog City
With photo

SUBSCRIBED AND SWORN to before me this ___ day of October 2022, at Dipolog
City.

DOC.NO.

PAGE NO.

BOOK NO.

SERIES OF 2022

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, JESSIE B. LAURENTE, of legal age, Filipino, single, a resident of New Sicayab,

Polanco, Zamboanga del Norte after having been duly sworn in accordance with
law, hereby depose and state:

That I am holder and possessor of an Official Receipt(OR) and Certificate of

Registration(CR) of motor vehicle,e a Yamaha Mio I125 with temporary plate
number 0901183003 issued by Land Transportation Office(LTO);

That recently, I discovered that said CR and OR were lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it
as totally lost;
As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
statements and for the purpose of attesting to the loss of the said CR and OR
issued by LTO.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

October 2022, at Dipolog City.

JESSIE B. LAURENTE
(Affiant)
UMID ID#CRN-021-1648-0704-1
With photo

SUBSCRIBED AND SWORN to before me this ___ day of October 2022, at Dipolog
City.

DOC.NO.

PAGE NO.

BOOK NO.

SERIES OF 2022

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, RAMIL LACQUIO LEBORES, of legal age, Filipino, married, a resident of Sicayan,

Dipolog City, Zamboanga del Norte after having been duly sworn in accordance
with law, hereby depose and state:

That I am holder and possessor of Driver’s License issued by LTO together with
OR, SSS card issued by SSS, vaccine card for COVID-19 and, Cebuana Lhuillier
Card;

That those documents were inside my wallet;

That on October 15, 2022, I discovered that my wallet containing those
documents including cash of P4,000.00 was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it
as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
statements and for the purpose of attesting to the loss of the said Driver’s License
with OR, SSS card, vaccine card, and Cebuana Lhuillier card

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

October 2022, at Dipolog City.

RAMIL LACQUIO LEBORES

(Affiant)
ID#________________
With photo

SUBSCRIBED AND SWORN to before me this ___ day of October 2022, at Dipolog
City.

DOC.NO.

PAGE NO.

BOOK NO.

SERIES OF 2022

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, GEOPHIL B. CULANAG, of legal age, Filipino, a resident of Delapa, Sibutad,

Zamboanga del Norte after having been duly sworn in accordance with law,
hereby depose and state:

That I am holder and possessor of an Official receipt(OR) with number

1593854544 issued by the LTO for the renewal of registration of motor vehicle
with Plate number MEU 134 owned by Du Ek Sam, Inc., my employer;
That in recently, I discovered that said OR was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it
as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
statements and for the purpose of attesting to the loss of the said OR.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

October 2022, at Dipolog City.

GEOPHIL B. CULANAG
(Affiant)
ID#________________
With photo

SUBSCRIBED AND SWORN to before me this ___ day of October 2022, at Dipolog
City.

DOC.NO.

PAGE NO.

BOOK NO.

SERIES OF 2022

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, MARIE C. REFUGIO, of legal age, Filipino, married, a resident of Dicayas, Dipolog City,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose
and state:

That I was holder of three(3) Receipts with numbers 0143-2021-00377,0143-2022—00851,

0143-2022-008821 issued by ML Lhuillier Pawnshop for Pawned Jewelies namely: YG PUL DEF
for an amount of P12,200.00; YG RING DEF for an amount of P7,200.00, and YG RING DEF for
an amount of P8,600.00, respectively .

That recently, while I was trying to locate the said receipts , but those were lost and could not
be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;
As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements
and for the purpose of attesting to the loss of the said receipts.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2022,
at Dipolog City.

MARIE C. REFUGIO
(Affiant)
Driver’s License#J01-00-034319 valid until 2023-08-22
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2022, at Dipolog City

Doc. No.

Page No.

Book No.

Series of 2022

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, NORVILYN MAE G. TAMAYO, of legal age, Filipino, single, a resident of

Brgy. Antonino, Labason, Zamboanga del Norte after having been duly
sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of Automated Teller Machine(ATM) card

with Account Number 00-5-27609-815-3 issued by Development Bank of the
Philippines;

That recently, I discovered that my said ATM card was lost;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.
As such, I am executing this Affidavit of Loss to attest to the truth of the
foregoing statements and for the purpose of attesting to the loss of the said
ATM card.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2021, at Dipolog City.

NORVILYN MAE G. TAMAYO

(Affiant)
PRC ID#0086303 until 4/12/2024-Medical Technologist
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2022, at

Dipolog City.

Doc. No.

Page No.

Book No.

Series of 2022

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, LEVIE J. LAQUIO, of legal age, Filipino, widow, a resident of Block 6, Lot

14, VCH, Obay, Polanco, Zamboanga del Norte, after having been duly
sworn in accordance with law, hereby depose and state:

That I was a holder and possessor of Passbooks of First Valley Bank with
Account Number 015-55-03993-8 and Rural Bank of Katipunan with Account
Number 001201119978 and an ATM card issued by Rural Bank of Katipunan
with Account Number 001310007217, all under the name of my late spouse
YOLANDO A. LAQUIO;

That recently, while I was trying to look for the said Passbooks and ATM card
from where I kept it, I found out that Passbooks and ATM card were lost, and
could not be found;
That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost;

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

foregoing statements and for the purpose of attesting to the loss of the said
Passbooks and ATM card.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2022, at Dipolog City.

LEVIE J. LAQUIO
(Affiant)
UMID ID#CRN-001-005202678-1
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2022, at

Dipolog City.

Doc No. _____

Page No. _____
Book No. ____
Series of 2022

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, SOLEDAD C. GREEN, of legal age, Filipino, married, a resident of

Sta.Filomena, Dipolog City, Zamboanga del Norte, after having been duly
sworn in accordance with law, hereby depose and state:

That I am the keeper of the Business Permit and Business Plate of Green
Commercial, located at Rizal Ave., Central Barangay, Dipolog City,
registered under my name;
That recently, while I was trying to look for the said business permit and
plate from where I kept it, I found out that the business plate and permit
were lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost;

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

foregoing statements and for the purpose of attesting to the loss of the said
business permit and plate.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2022, at Dipolog City.

SOLEDAD C. GREEN
(Affiant)
Driver’s License#J01-08-003544
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2022, at

Dipolog City.

Doc No. _____

Page No. _____
Book No. ____
Series of 2022

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x
 AFFIDAVIT OF LOSS

I, ANGELINA R. CAIDET, of legal age, Filipino, widow, a resident of San Antonio,

Polanco, Zamboanga del Norte after having been duly sworn in accordance with
law, hereby depose and state:

That I am holder and possessor of an Official receipt(OR) with number 8487826

issued by the Province of Zamboanga del Norte for the oayment of transfer tax;

That in recently, I discovered that said OR was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it
as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
statements and for the purpose of attesting to the loss of the said OR.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

October 2022, at Dipolog City.

ANGELINA R. CAIDET
(Affiant)
ID#________________
With photo

SUBSCRIBED AND SWORN to before me this ___ day of October 2022, at Dipolog
City.

DOC.NO.

PAGE NO.

BOOK NO.

SERIES OF 2022

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x
 AFFIDAVIT OF LOSS

I, MAGNOLIA U. SAILE, of legal age, Filipino, married, a resident of Martinez

Village, Turno, Dipolog CIty, Zamboanga del Norte after having been duly sworn
in accordance with law, hereby depose and state:

That I am holder and possessor of a Driver’s License together with its Official
Receipt(OR) issued by Land Transportation Office(LTO);

That in recently, I discovered that said Driver’s License card and its original OR
were lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it
as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
statements and for the purpose of attesting to the loss of the said Driver’s License
card with OR issued by LTO.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

October 2022, at Dipolog City.

MAGNOLIA U. SAILE
(Affiant)
Driver’s License#J01-00-033319
With photo

SUBSCRIBED AND SWORN to before me this ___ day of October 2022, at Dipolog
City.

DOC.NO.

PAGE NO.

BOOK NO.

SERIES OF 2022

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS
I, MARICAR P. PELERA, of legal age, Filipino, widow, a resident of Estaka,
Dipolog City, Zamboanga del Norte, after having been duly sworn in
accordance with law, hereby depose and state:

That I was a holder and possessor of PAFCPIC Passbook, PAFCPIC ID, and
PAFCPIC Share and Share Certificate, all under the name of my late spouse
ARCHIE ACOPIADO PELERA;

That recently, while I was trying to look for the said PAFCPIC Passbook,
PAFCPIC ID, and PAFCPIC Share and Share Certificate from where I kept it, I
found out that PAFCPIC Passbook, PAFCPIC ID, and PAFCPIC Share and Share
Certificate were lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost;

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

foregoing statements and for the purpose of attesting to the loss of the said
PAFCPIC Passbook, PAFCPIC ID, and PAFCPIC Share and Share Certificate.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2022, at Dipolog City.

MARICAR P. PELERA
(Affiant)
Driver’s License#J01-14-003751
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2022, at

Dipolog City.

Doc No. _____

Page No. _____
Book No. ____
Series of 2022

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS
I, NORHIDA E. JAILAN, of legal age, Filipino, single, a resident of Caracol, Salug,
Zamboanga del Norte after having been duly sworn in accordance with law,
hereby depose and state:

That I was a holder and possessor of a Philippine National Bank Passbook with
Account No.412810013697 opened on 11/05/1996 in Dipolog City Branch.

That recently, I found out that said passbook was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it
as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
statements and for the purpose of attesting to the loss of the said passbook.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2022, at Dipolog City.

NORHIDA E. JAILAN
(Affiant)
Phil.Passport#P8763408A
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2022, at Dipolog
City.

DOC.NO.

PAGE NO.

BOOK NO.

SERIES OF 2022

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS
I, MARICAR P. PELERA, of legal age, Filipino, widow, a resident of Estaka,
Dipolog City, Zamboanga del Norte, after having been duly sworn in
accordance with law, hereby depose and state:

That I was a holder and possessor of an AFPSLAI Red Passbook, AFPSLAI

Yellow Passbook and AFPSLAI Green Passbook issued by AFPSLAI together
with AFPSLAI ID and ACDI Multipurpose Cooperative Passbook and ACDI ID,
all under the name of my late spouse ARCHIE ACOPIADO PELERA;

That recently, while I was trying to look for the said Passbooks and IDs from
where I kept it, I found out that the Passbooks and IDs were lost, and could
not be found;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost;

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

foregoing statements and for the purpose of attesting to the loss of the said
AFPSLAI Red Passbook, AFPSLAI Yellow Passbook and AFPSLAI Green
Passbook issued by AFPSLAI together with AFPSLAI ID and ACDI
Multipurpose Cooperative Passbook and ACDI ID.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2022, at Dipolog City.

MARICAR P. PELERA
(Affiant)
Driver’s License#J01-14-003751
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2022, at

Dipolog City.

Doc No. _____

Page No. _____
Book No. ____
Series of 2022
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, MA ROWENA B. HALOC, of legal age, Filipino, married, a resident of New

Dapitan, Rizal, Zamboanga del Norte after having been duly sworn in accordance
with law, hereby depose and state:

That I am the Municipal Treasurer of LGU-Rizal, Zamboanga del Norte;

That I was a holder and possessor of a Development Bank of the Philippines Check
with Number 0066374066 under Account No.0-01068-815-0 dated August 19,
2022 with an amount of P351,815.62 for payee MRTS CONSTUCTION SERVICES.

That recently, I found out that said check was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it
as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
statements and for the purpose of attesting to the loss of the said check .

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2022, at Dipolog City.

MA. ROWENA B. HALOC

(Affiant)
LGU-Rizal, ZN Employee’s ID#385-033
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2022, at Dipolog
City.

DOC.NO.

PAGE NO.

BOOK NO.

SERIES OF 2022
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, CHRISTINE T. ANDAG, of legal age, Filipino, married, a resident of Road 31,

Dawon, Dapitan City, Zamboanga del Norte after having been duly sworn in
accordance with law, hereby depose and state:

That I was a holder and possessor of a Development Bank of the Philippines Check
with Number 78861148 issued by ZN Cooperative Hospital with an amount of
P16,300.00.

That it was issued to payee SECC, my employer;

That recently, I was informed that said check was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it
as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
statements and for the purpose of attesting to the loss of the said check .

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2022, at Dipolog City.

CHRISTINE T. ANDAG
(Affiant)
Philippine Health Insurance Corp ID#14-050109961-5
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2022, at Dipolog
City.

DOC.NO.

PAGE NO.

BOOK NO.

SERIES OF 2022
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ESTRELLITA BALAGOT ANGUILID, of legal age, Filipino, married, a

resident of Purok Orchid, National Highway, Sicayab, Dipolog City,
Zamboanga del Norte, after having been duly sworn in accordance with law,
hereby depose and state:

That I am a holder and possessor of a Policy Contract, CHSI

Membership/Green Card, and Certificate of Full Payment/Notice of Full
Payment issued by Caritas Health Shield, Inc.;

That in recently, while I was trying to look for the said Policy Contract CHSI
Membership/Green Card, and Certificate of Full Payment/Notice of Full
Payment from my file where I kept it, I found out that the documents were
lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost;

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

foregoing statements and for the purpose of attesting to the loss of the said
Policy Contract, CHSI Membership/Green Card, and Certificate of Full
Payment/Notice of Full Payment issued by Caritas Health Shield, Inc.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

October 2022, at Dipolog City.

ESTRELLITA B. ANGUILID
(Affiant)
OSCA ID#9290-Dipolog City
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of October 2022, at

Dipolog City.

DOC. NO.

PAGE NO.
BOOK NO.

SERIES OF 2022

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, EDWIN T. SANICO, of legal age, Filipino, married, a resident of Langatian,

Pres.MA ROxas, Zamboanga del Norte after having been duly sworn in
accordance with law, hereby depose and state:

That I am holder and possessor of a Official Receipt(OR) with number 2169679293

of motor vehicle with MV File No.090100000382985, Plate No.090810 issued by
Land Transportation Office(LTO);

That in recently, I discovered that said original OR was lost, and could not be
found;

That despite effort to recover the same but it was naught. Hence, I considered it
as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
statements and for the purpose of attesting to the loss of the said OR issued by
LTO.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

October 2022, at Dipolog City.

EDWIN T. SANICO
(Affiant)
Driver’s License#J01-12-000003
With photo

SUBSCRIBED AND SWORN to before me this ___ day of October 2022, at Dipolog
City.

DOC.NO.
PAGE NO.

BOOK NO.

SERIES OF 2022

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, JOEL C. HAMOC, of legal age, Filipino, single/married, a resident of San Antonio,

Polanco, Zamboanga del Norte after having been duly sworn in accordance with
law, hereby depose and state:

That I am holder and possessor of a driver’s license(ID) issued by Land

Transportation Office(LTO) and license as security guard;

That recently, I discovered that my said driver’s license ID and license as a guard
was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it
as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
statements and for the purpose of attesting to the loss of the said driver’s license
by LTO and license as a security guard.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

October 2022, at Dipolog City.

JOEL C. HAMOC
(Affiant)
Driver’s License#J01-17-002299
With photo
SUBSCRIBED AND SWORN to before me this ___ day of October 2022, at Dipolog
City.

DOC.NO.

PAGE NO.

BOOK NO.

SERIES OF 2022
Acknowledgment Receipt

I, ARCELITA YBANEZ, of legal age, Filipino, widow, resident of San Antonio, Polanco, Zamboanga del
Norte, am the owner of portion of property known as LOT 4606-F with an area of 5,434 square meters covered
by Transfer Certificate of Title No.127-T-3479.

I hereby received the amount of Eight Thousand (P8,000.00)Pesos from HANNAH LOU G. MANDANTES
representing my loan and I hereby utilize the one-half of the above-said parcel of land as collateral.

In witness whereof, I signed this September 30, 2022 at Polanco, ZN.

ARCELITA YBANEZ

Witnesses:_________________________and_____________________________

Ako si, ARCELITA YBANEZ, of legal age, Filipino, widow, resident of San Antonio, Polanco, Zamboanga del
Norte, tag-iya sa lot nga LOT 4606-F nga duna gidak-on nga 5,434 square meters titulo na Transfer Certificate
of Title No.127-T-3479.

Ako nadawat ang kantidad nga OTSO MIL(Eight Thousand Pesos) gikan kang HANNAH LOU G.
MANDANTES isip akong utang ug himoon nako ang katunga sa maong yuta isip akong kolateral.

Akong pagapirmahan karon Setyembre 30, 2022 sa Polanco, ZN.

ARCELITA YBANEZ

Testigos:__________________________ug__________________________

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x
 AFFIDAVIT OF LOSS

I, DULCITA SIBYA DIAMANTE, of legal age, Filipino, married, resident of Block 12, Lot 10, VCH, Obay,
Polanco, Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am the daughter of late Spouses Bernardita Cordero and Benjamin Sibya, registered owner of a parcel of
land, more particularly described as follows:

A parcel of land known as Lot No.G, Psd-145987, covered by Transfer Certificate of Title No.T-17924 situated
at Poblacion, Roxas, Zamboanga del Norte, containing an area of 1,283 square meters issued by the Register of
Deeds for Zamboanga del Norte.

That the owner’s copy of the title was turned over to me by older sibling however when I and my siblings were
about to partition the said parcel of land, I discovered that the owner’s copy of the title was lost;

That despite effort to recover the same but it was naught.

That I considered it as totally lost.

That I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for the purpose
of attesting to the loss of the said owner’s copy of Transfer Certificate of Title No.T-17924.

IN WITNESS WHEREOF, I have hereunto affixed my signature this __th day of _______ 2022, at Dipolog
City.

DULCITA SIBYA-DIAMANTE

(Affiant)

PRC ID#0653058 valid until 10/25/2025

With photo

SUBSCRIBED AND SWORN to before me this ___th day of ________ 2022, at Dipolog City.

DOC.NO. ______

PAGE NO.___

BOOK NO.___

SERIES OF 2022
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, LOVELY L. ACOL, of legal age, Filipino, single, a resident of Lugdungan, Dipolog City, Zamboanga del
Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am holder and possessor of my sister JEZA L. ACOL’s DIPLOMA and Form 137 or card issued
ZNNHS-Main Campus, Dipolog City;

That I discovered that the original copy of her Diploma, good moral and Form 137 were lost, and
could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said Diploma, good moral, and Form 137.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2022, at
Dipolog City.

LOVELY L. ACOL
(Affiant)
Philhealth ID#14-025373708-1
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2022, at Dipolog City.

Doc. No.

Page No.

Book No.

Series of 2022
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, CESAR L. GONZAGA, of legal age, Filipino, single/married, a resident of Guinles,

Polanco, Zamboanga del Norte after having been duly sworn in accordance with
law, hereby depose and state:

That I was a holder and possessor of a sepia copy and corresponding Technical
Descriptions of Approved Subdivision Plan PSD-09-_______________ for parcel of
land situated at Guinles, Polanco, Zamboanga del Norte.

That sometime third week of June 2022, while I was checking my file folder
containing the said document so that I could process the land and its revision, I
found out that the technical description documents were lost, and could not be
found;

That despite effort to recover the same but it was naught. Hence, I considered it
as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
statements and for the purpose of attesting to the loss of the said sepia copy and
technical descriptions documents and request for replacement of the same.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2022, at Dipolog City.

CESAR L. GONZAGA

(Affiant)

SSS ID#10-0563846-3

With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2022, at Dipolog
City.
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, MANILYN P. CLATERO, of legal age, Filipino, single, a resident of Mias,

Katipunan, Zamboanga del Norte after having been duly sworn in
accordance with law, hereby depose and state:

That I was a holder and possessor of a Philippine Passport with number

P9069683B issued by the Department of Foreign Affairs;

That recently, I found out that my said passport was missing after it fell out
from my bag while I traveled from Dapitan City Seaport to my house at
Katipunan, Zamboanga del Norte;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
passport.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2022, at Dipolog City.

MANILYN P. CLATERO
(Affiant)
Driver’s License#J01-17-003818
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2022, at

Dipolog City.

Doc. No.___

Page No.___

Book No.___

Series of 2022
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, SHANON P. LUMANAO, of legal age, Filipino, single, a resident of South Proper, Galas, Dipolog City,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of the original copy official receipt for payment of Philippine Health
Insurance Corporation(PHIC) premium remittances of BEL ESPRIT INC. at CIS Bayad Center, Inc-LBC
Lee Plaza, Dipolog City for the month of July 2020. An Official Receipt dated September 17, 2020 has
number of 773309172000055 and amount of P8,100.00.

That recently while I was trying to look for said official receipt, I found out that the receipt’s print is
not visible anymore and it is incomprehensible to read thus it was considered lost;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said official receipt.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2022, at
Dipolog City.

SHANON P. LUMANAO
(Affiant)
Driver’s License#J01-20-011418
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2022, at Dipolog City.

Doc. No
Page No
Book No
Series of 2022
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, JOSEPH STALIN O. JATICO of legal age, Filipino, a resident of Sta. Isabel, Dipolog City, Zamboanga
del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of the original copy Motorized Tricycle Operator’s Permit(MTOP)
issued by Local Government of Dipolog City with MTOP DPLG NO. 2021-1846 with Expiry date of
October 2022 registered under my name.

That recently while I was trying to look for the MTOP of my tricycle, I found out that the it was lost,
and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said MTOP.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2022, at
Dipolog City.

JOSEPH STALIN O. JATICO

(Affiant)
Driver’s License#J01-13-002539
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2022, at Dipolog City.

Doc. No
Page No
Book No
Series of 2022
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, JOSEPH WILSON I. JATICO of legal age, Filipino, a resident of Sta. Isabel, Dipolog City, Zamboanga
del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of the original copy Motorized Tricycle Operator’s Permit(MTOP)
issued by Local Government of Dipolog City with MTOP DPLG NO. 2021-1847 with Expiry date of
September 2022 registered under my name.

That recently while I was trying to look for the MTOP of my tricycle, I found out that the it was lost,
and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said MTOP.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2022, at
Dipolog City.

JOSEPH WILSON I. JATICO

(Affiant)
Driver’s License#J01-81-003534
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2022, at Dipolog City.

Doc. No
Page No
Book No
Series of 2022
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, JOSE MARI M. APILAN, of legal age, Filipino, married, a resident of South

Proper, Galas, Dipolog City, Zamboanga del Norte, after having been duly
sworn in accordance with law, hereby depose and state:

That I was a holder and possessor of an AFPSLAI Red Passbook and AFPSLAI
Green Passbook issued by AFPSLAI;

That recently, while I was trying to look for the said AFPSLAI Passbooks from
where I kept it, I found out that the AFPSLAI Passbooks were lost, and could
not be found;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost;

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

foregoing statements and for the purpose of attesting to the loss of the said
AFPSLAI Red Passbook and AFPSLAI Green Passbook.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2022, at Dipolog City.

JOSE MARI M. APILAN

(Affiant)
Driver’s License#J01-05-003448
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2022, at

Dipolog City.
Doc No. _____
Page No. _____
Book No. ____
Series of 2022

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, DIONISIO P. ABAL, of legal age, Filipino, married, a resident of De Venta Perla,

Polanco, Zamboanga del Norte after having been duly sworn in accordance with
law, hereby depose and state:

That I am holder and possessor of a driver’s license(ID) issued by Land

Transportation Office(LTO);

That recently, I discovered that my said driver’s license ID was lost, and could not
be found;

That despite effort to recover the same but it was naught. Hence, I considered it
as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
statements and for the purpose of attesting to the loss of the said driver’s license
by LTO.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

September 2022, at Dipolog City.

DIONISIO P. ABAL
(Affiant)
Voter’s ID#7210-0027B-L1568DPA10000-4
With photo

SUBSCRIBED AND SWORN to before me this ___ day of September 2022, at

Dipolog City.

DOC.NO.
PAGE NO.

BOOK NO.

SERIES OF 2022

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT

I, REYMOND APLACA SUMAMBOD, of legal age, Filipino, single, a resident of

Galokso, Pres. Manuel A. Roxas, Zamboanga del Norte after having been
duly sworn in accordance with law, hereby depose and state:

That I am a member of the Bureau of Fire Protection(BFP) with a position of

Fire Officer I;

That I am currently assigned at Dinas Fire Station with address of Poblacion,

Dinas, Zamboanga del Sur;

That I have been reporting at the said station for more than a year;

That on September 10, 2022 at around 1:35 in the afternoon, I received a

facebook messanger message a certain “Jade” account stating that I must
not appear and show myself in Dinas;

That the message stated that “pahawa na lang ug Dinas yawaa ka..Gigubot
nimu ko pamilya ug relasyon nmu mg asawa…dako kaayo ka salaud imo
gibuhat..kabalo ka minyu ko asawa nkig relasyunay jud mo…”; “kabalo b
aka sa nahitabo namu karon?yawaa ka”; “yawaaaaaa ka tawhana…pahawa
na lng jud sa dinas”;

That I was distressed and alarmed with the said messages;

That since then I felt that my life is at risk and threaten with physical harm
by particular persons in Dinas;
That today I was supposedly would render my duty however the threat on
my life and security has persisted;

That I therefore asked my superior that I could not report on todays tour of
duty and that I respectfully request my immediate reassignment in another
area so that I could effectively render my work without risk or threat on my
life other than occupational rrisk as a firefighter;

That I attest the truthfulness of foregoing statement;

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2022, at Dipolog City.

REYMOND APLACA SUMAMBOD

(Affiant)
Drivers License#J01-19-007833
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2022, at

Dipolog City.

Doc. No.___

Page No.___

Book No.___

Series of 2022
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, MARICEL D. BONOCAN, of legal age, Filipino, single, a resident of De Venta

Perla, Polanco, Zamboanga del Norte after having been duly sworn in
accordance with law, hereby depose and state:

That I was a holder and possessor of a Philippine Passport issued by the

Department of Foreign Affairs;

That recently, I found out that my said passport was missing;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.
As such, I am executing this Affidavit of Loss to attest to the truth of the
foregoing statements and for the purpose of attesting to the loss of the said
passport.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2022, at Dipolog City.

MARICEL D. BONOCAN
(Affiant)
TIN#284-566-717
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2022, at

Dipolog City.

Doc. No.___

Page No.___

Book No.___

Series of 2022

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, JULIETA M. DARUNDAY, of legal age, Filipino, single/married, a resident of Sergio Osmena,

Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I was a holder and possessor of a duplicate copy of Bureau of Internal Revenue(BIR)’s eCAR with
#eCR201600124836 as well the document of conveyance;

That recently, while I was trying to look for the said copy, but it was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;
As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said eCAR and reissuance of the same.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2022, at
Dipolog City.

JULIETA M. DARUNDAY
(Affiant)
TIN ID#49404910875
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2022, at Dipolog City.

Doc. No.
Page No.
Book No.
Series of 2022

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x
 AFFIDAVIT OF LOSS

I, JULIETA M. DARUNDAY, of legal age, Filipino, single/married, a resident of Sergio Osmena,

Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I was a holder and possessor of a duplicate copy of Bureau of Internal Revenue(BIR)’s eCAR with
#eCR201600124835 as well the document of conveyance;

That recently, while I was trying to look for the said copy, but it was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said eCAR and reissuance of the same.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2022, at
Dipolog City.

JULIETA M. DARUNDAY
(Affiant)
TIN ID#49404910875
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2022, at Dipolog City.

Doc. No.
Page No.
Book No.
Series of 2022
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, EMMANUEL C. QUINANOLA, of legal age, Filipino, married, a resident of

Poblacion South, Polanco, Zamboanga del Norte after having been duly sworn in
accordance with law, hereby depose and state:

That I am holder and possessor of a Official Receipt(OR) and Certificate of

Registration(CR) of motor vehicle with Engine No.G3HADM224107 and Chassis
No.MALA251AAEM249242 issued by Land Transportation Office(LTO);

That in June 2022, I discovered that said CR and OR were lost, and could not be
found;

That despite effort to recover the same but it was naught. Hence, I considered it
as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
statements and for the purpose of attesting to the loss of the said CR and OR
issued by LTO.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

August 2022, at Dipolog City.

EMMANUEL C. QUINANOLA
(Affiant)
ID#_________________________
With photo

SUBSCRIBED AND SWORN to before me this ___ day of August 2022, at Dipolog
City.

DOC.NO.

PAGE NO.

BOOK NO.

SERIES OF 2022
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, RHEA LYNN GURDIEL BERNADAS, of legal age, Filipino, married, a resident of Sta. Isabel,
Dipolog City, Zamboanga del Norte after having been duly sworn in accordance with law,
hereby depose and state:

That I was holder of two(2) Receipts with numbers 0240-2022-00217 and 0240-2021-00539
issued by ML Lhuillier Pawnshop for Pawned Jewelies namely: Pendant Yg Def ,18K,0.7 grams
and Earring PR WG W. BS DEF, 14K, 3.0 grams, respectively .

That recently, while I was trying to locate the said receipts , but those were lost and could not
be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements
and for the purpose of attesting to the loss of the said receipts.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2022,
at Dipolog City.

RHEA LYNN GURDIEL BERNADAS

(Affiant)
UMID ID#CRN-0111-2187229-7
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2022, at Dipolog City

Doc. No.

Page No.

Book No.

Series of 2022
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ROSARIO L. GURDIEL, of legal age, Filipino, widow, a resident of Sta. Isabel,

Dipolog City, Zamboanga del Norte after having been duly sworn in accordance
with law, hereby depose and state:

That I was holder and possessor of OSCA Identification(ID) card issued by Office of
Senior Citizen’s Affairs(OSCA).

That in first week of August 2022, I discovered that my said OSCA ID card was
lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it
as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
statements and for the purpose of attesting to the loss of the said OSCA ID card.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

August 2022, at Dipolog City.

ROSARIO L. GURDIEL
(Affiant)
PRC ID#0016936-Pharmacist
With photo

SUBSCRIBED AND SWORN to before me this ___ day of August 2022, at Dipolog
City.

DOC.NO.

PAGE NO.
BOOK NO.

SERIES OF 2022

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

We, Spouses BONNIE D. MOLINA and CECELIA M. MOLINA, both of legal age, both Filipinos, both
residents of Egot, Turno, Dipolog City, Zamboanga del Norte after having been duly sworn in accordance with
law, hereby depose and state:

That we are the owners of a parcel of land, more particularly described as follows:

A parcel of land known as Lot No.590-J, covered by Transfer Certificate of Title No.T-68186 situated at
Bitoon(now Disud), Sindangan, Zamboanga del Norte, containing an area of 197 square meters issued by the
Register of Deeds for Zamboanga del Norte.

That we purchased it from Jeverina C. Paredes who turned over the owner’s copy of the title after we executed
the deed of sale;

That recently we processed the transfer of title and we found out that the owner’s copy of title is lost;

That despite effort to recover the same but it was naught.

That we considered it as totally lost.

That we are executing this Affidavit of Loss to attest to the truth of the foregoing statements and for the purpose
of attesting to the loss of the said owner’s copy of Transfer Certificate of Title No.T-68186.

IN WITNESS WHEREOF, we have hereunto affixed our signatures this __th day of _______ 2022, at Dipolog
City.

BONNIE D. MOLINA CECELIA M. MOLINA

(Affiant) (Affiant)
TIN#927-081-347 TIN#933-804-042

SUBSCRIBED AND SWORN to before me this ___th day of ________ 2022, at Dipolog City.

DOC.NO. ______

PAGE NO.___

BOOK NO.___

SERIES OF 2022

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF JUSTIFICATION

I, ROSALINA T. SALAVERIA, of legal age, Filipino, single, a resident of Estaka, Dipolog City,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am the attorney-in-fact of Glen T. Salaveria for the authorization on sale his parcel of land
covered by TCT No. T-10904 which was notarized by Atty Rodolfo Guimbarda under Doc. No.6534,
Page No.60, Book No. XV, Series of 201;

That after the original copies of the document were under my custody I have kept its original copies
however after I transacted with the buyer for the sale of the said parcel of land I found out that all of
original copies were given to various persons and all that was left to me is the photostatic copy only so
we went to Atty Guimbarda for the certification as to authenticity of the photostatic copy;

That despite certification of photostatice copy, I tried to locate the original copy but nothing is availed

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said original copy of Special Power of Attorney.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2022, at
Dipolog City.

ROSALINA T. SALAVERIA
(Affiant)
SSS ID#03-192004270
 With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2022, at Dipolog City.

Doc. No.

Page No.

Book No.

Series of 2022

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, LELLANN L. CARBALLO, of legal age, Filipino, married, a resident of Turno, Dipolog City,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am an owner of a cellular phone with Two(2) Sim Cards with Number 09105380899(Talk’n
Text) and Number 09151563330(Globe) ;

That my said cellular phone with said sim cards was used in all important transactions;

That recently my said phone was lost;

That it could not be found anymore;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;
As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said sim cards and thereafter requesting replacement of the
same.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2022, at
Dipolog City.

LELLANN L. CARBALLO
(Affiant)
Voters ID#7218-0127D-I1588LLC20000
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2022, at Dipolog City.

Doc. No.

Page No.

Book No.

Series of 2022

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT

I, EDDIE LATA PARMOSA, of legal age, Filipino, married, a resident of

Luzvilla, Pinan, Zamboanga del Norte after having been duly sworn in
accordance with law, hereby depose and state:

That I am an heir of my late father Samuel Parmosa;

That my father is occupant and possessor a parcel of land known as Lot

361, situated at Penacio, Sergio Osmena, Zamboanga del Norte,from Felix
Buhisan;
That adjacent to Lot 361 are Lots 372 and 373 which are actually occupied
and possessed by late Amado Buhisan;

That since immemorial it was Amado Buhisan who occupied and possessed
the said parcels of land, Lots 372 and 373;

That I physically witnessed that Amado Buhisan cultivated the said parcels
of land with coconuts and abaca and he is known as the owner of the said
parcels of land;

That in 1980s Amado Buhisan with his heirs entrusted the care and
management of said parcels of land due to presence of NPA rebels in the
area;

That I continue to administer his lands and even reported his share of the
plants like the coconut and abaca;

That Francisca Budburan occupied a portion of the lands of Buhisan, but not
entirely which was tolerated by undersigned because she was planting
crops for her subsistence. Francisca Budburan only came later 2000’s.

That I was informed that Willer Cornelio, Gerson Cornelio, Germa Cornelio
and Carlito Caroro purchased the said parcels of land from Francisca
Budburan, but Francisca Budburan was not the owner because it is owned
by Amado Buhisan;

That Cornelios and Budburan are never landowners and did not ever
cultivated in concept of an owner any lots near to my relatives

That the heirs of Amado Buhisan continue to occupy and possess the said
parcels of land through undersigned who frequented the said parcels of
land;

That I gather the fruits of the said parcels of land to Amado Buhisan;

That I understand my said statements and it was translated into Cebuano

which is understood by me;

That I am voluntarily executing and attesting the truthfulness of my

abovestatements in order to support the claims of heirs of Amado Buhisan
on their ownership claims over Lots 372 and 373, situated in Penacio, Sergio
Osmena, Zamboanga del Norte.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2022, at Dipolog City.

EDDIE LATA PARMOSA

(Affiant)
Philhealth ID#14-200986983-1
With photo
SUBSCRIBED AND SWORN to before me this ___ day of _________ 2022, at
Dipolog City.

Doc. No.___

Page No.___

Book No.___

Series of 2022
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT

I, ELVIE PACANTE TAN, of legal age, Filipino, married, a resident of Teresita,

Pinan, Zamboanga del Norte after having been duly sworn in accordance
with law, hereby depose and state:

That I am an heir of my late mother Isidra Pacante Tan;

That my mother purchased a parcel of land known as Lot 376, situated at

Penacio, Sergio Osmena, Zamboanga del Norte,from Felix Buhisan;

That adjacent to Lot 376 are Lots 372 and 373 which are actually occupied
and possessed by late Amado Buhisan;

That Felix Buhisan, seller of parcel of land bought by my mother is the

cousin of Amado Buhisan;

That since immemorial it was Amado Buhisan who occupied and possessed
the said parcels of land, Lots 372 and 373;

That I physically witnessed that Amado Buhisan cultivated the said parcels
of land with coconuts and abaca and he is known as the owner of the said
parcels of land;

That Gerson Cornelio, Willer Cornelio, Carlito Caroro, Francisca Budburan

and Germa Cornelio only came later. That I was informed that Cornelios
purchased the said parcels of land from Francisca Budburan, but Francisca
Budburan was not the owner because it is owned by Amado Buhisan;

That Amado Buhisan entrusted his neighbor Eddie Parmosa, heir of Samuel
Parmosa, owner of adjacent Lot 361. That Eddie Parmosa is grandson of
Ricardo Lata, then owner of Lot 363, Lot 370 and Lot 371 and Eddie
Parmosa is also grandnephew of Miguel Lata, then owner of Lot 362. That all
of these lots are occupied and possessed in concept of an owner by my
relatives including Amado Buhisan. That my grandfather Ricardo Lata and
Miguel Lata sold their land s latter.

That Cornelios and Budburan are never landowners and did not ever
cultivated in concept of an owner any lots near to my relatives

That the heirs of Amado Buhisan continue to occupy and possess the said
parcels of land through Eddie Parmosa who frequented the said parcel of
land due to relocation of heirs of Amado Buhisan in Roxas, Zamboanga del
Norte due to threats from rebels;
That Eddie Parmosa gathers the fruits of the said parcels of land to Amado
Buhisan;

That I understand my said statements and it was translated into Cebuano

which is understood by me;

That I am voluntarily executing and attesting the truthfulness of my

abovestatements in order to support the claims of heirs of Amado Buhisan
on their ownership claims over Lots 372 and 373, situated in Penacio, Sergio
Osmena, Zamboanga del Norte.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2022, at Dipolog City.

ELVIE PACANTE TAN

(Affiant)
Philhealth ID#14-200922943-3
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2022, at

Dipolog City.

Doc. No.___

Page No.___

Book No.___

Series of 2022
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, JE ANN OTAP TAYRUS, of legal age, Filipino, single, a resident of Miputak,

Dipolog CIty, Zamboanga del Norte after having been duly sworn in
accordance with law, hereby depose and state:

That I am a holder and possessor of a Philippine Passport issued by the

Department of Foreign Affairs;

That on June 12, 2022, I found out that my said passport was missing;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
passport.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2022, at Dipolog City.

JE ANN OTAP TAYRUS

(Affiant)
UMID ID#CRN-0111-3072758-2
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2022, at

Dipolog City.

Doc. No.___

Page No.___

Book No.___

Series of 2022
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ALBERTO G. LUMAYAM,JR, of legal age, Filipino, single/married, a resident of

Loyuran, Katipunan, Zamboanga del Norte after having been duly sworn in
accordance with law, hereby depose and state:

That I am holder and possessor of a Official Receipt(OR) and Certificate of

Registration(CR) of motor vehicle with number 14176140 issued by Land
Transportation Office(LTO);

That in June 2022, I discovered that said CR and OR were lost, and could not be
found;

That despite effort to recover the same but it was naught. Hence, I considered it
as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
statements and for the purpose of attesting to the loss of the said CR and OR
issued by LTO.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

August 2022, at Dipolog City.

ALBERTO G. LUMAYAM,JR
(Affiant)
Driver’s License#J01-10-001205
With photo

SUBSCRIBED AND SWORN to before me this ___ day of August 2022, at Dipolog
City.

DOC.NO.

PAGE NO.

BOOK NO.

SERIES OF 2022
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ANITA L. DIAO, of legal age, Filipino, married, a resident of San Nicolas, Dapitan City, Zamboanga del
Norte after having been duly sworn in accordance with law, hereby depose and state:

That I was a holder and possessor of a duplicate copy of Bureau of Internal Revenue(BIR)’s eCAR
201600621428;

That recently, while I was trying to look for the said duplicate copy, but it was lost, and could not be
found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said eCAR and reissuance of the same.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2022, at
Dipolog City.

ANITA L. DIAO
(Affiant)
TIN ID#126-778-221
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2022, at Dipolog City.

Doc. No.
Page No.
Book No.
Series of 2022

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, NORA A. FULGUERAS, of legal age, Filipino, married, a resident of

Poblacion Alto, Sergio Osmena, Zamboanga del Norte, after having been
duly sworn in accordance with law, hereby depose and state:

That I was a holder and possessor of a Passbook issued by 1 st Valley Bank,

Inc.-Dipolog City, Zamboanga del Norte Branch, Passport issued by the
Department of Foreign Affairs and Philippine Veteran’s Affairs Office(PVAO)
documents of my grandfather Antonio M. Balolong;

That on April 6, 2022, my house was razed with fire. That the said
documents were included to the things that were razed with fire;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost;

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

foregoing statements and for the purpose of attesting to the loss of the said
Passbook, Passport and PVAO documents of my grandfather.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

July 2022, at Dipolog City.

NORA A. FULGUERAS
(Affiant)
UMID ID#CRN-006-0075-4601-1
With Photo
SUBSCRIBED AND SWORN to before me this ___ day of July 2022, at Dipolog
City.

Doc. No.

Page No.

Book No.

Series of 2022

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, SALLY UNDE QUIZO, of legal age, Filipino, single, a resident of Purok

Bougainvilla, Sicayab, Dipolog City, Zamboanga del Norte after having been duly
sworn in accordance with law, hereby depose and state:

That I was holder and possessor of appointment form/document for renewal of my

PRC license as registered nurse.

That recentl, I discovered that my said appointment form/document was lost, and
could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it
as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
statements and for the purpose of attesting to the loss of the said appointment
form/document.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of July
2022, at Dipolog City.

SALLY UNDE QUIZO

(Affiant)
 SSS ID#10-0687540-3
With photo

SUBSCRIBED AND SWORN to before me this ___ day of July 2022, at Dipolog City.

DOC.NO.

PAGE NO.

BOOK NO.

SERIES OF 2022

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, DELIA A. CAMOTA, of legal age, Filipino, single/married, a resident of VCH, Obay,

Polanco, Zamboanga del Norte after having been duly sworn in accordance with
law, hereby depose and state:

That I was a holder and possessor of a sepia copy and corresponding Technical
Descriptions of Approved Subdivision Plan PSD-09-010727 for parcel of land
situated at Magangon, Polanco, Zamboanga del Norte.

That sometime third week of June 2022, while I was checking my file folder
containing the said document so that I could process the land and its revision, I
found out that the technical description documents were lost, and could not be
found;

That despite effort to recover the same but it was naught. Hence, I considered it
as totally lost.
As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
statements and for the purpose of attesting to the loss of the said sepia copy and
technical descriptions documents and request for replacement of the same.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2022, at Dipolog City.

DELIA A. CAMOTA

(Affiant)

OSCA ID#18-03396-Polanco,ZN

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2022, at Dipolog
City.

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ARCHIVAL M. PUGOY, of legal age, Filipino, single, a resident of Galas, Dipolog

City, Zamboanga del Norte after having been duly sworn in accordance with law,
hereby depose and state:

That I am holder and possessor of an identification card being a member of

Philippine National Police(PNP) which was issued by the PNP.

That in July 2022, I discovered that my said PNP ID card was lost, and could not be
found;

That despite effort to recover the same but it was naught. Hence, I considered it
as totally lost;
As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
statements and for the purpose of attesting to the loss of the said PNP ID card.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of July
2022, at Dipolog City.

ARCHIVAL M. PUGOY
(Affiant)
Driver’s License#J01-11-004298 valid until 2022/10/29
With photo

SUBSCRIBED AND SWORN to before me this ___ day of July 2022, at Dipolog City.

DOC.NO.

PAGE NO.

BOOK NO.

SERIES OF 2022

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, SANTIAGO MAGSAYO ANDAG, of legal age, Filipino, married, a resident of Dawo,

Dapitan CIty, Zamboanga del Norte after having been duly sworn in accordance
with law, hereby depose and state:

That I am holder and possessor of a driver’s license(ID) issued by Land

Transportation Office(LTO) and Official Receipt(OR).
That in June 2022, I discovered that my said driver’s license ID and OR were lost,
and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it
as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
statements and for the purpose of attesting to the loss of the said driver’s license
and OR issued by LTO.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of July
2022, at Dipolog City.

SANTIAGO MAGSAYO ANDAG

(Affiant)
OSCA ID#008966-Dapitan City
With photo

SUBSCRIBED AND SWORN to before me this ___ day of July 2022, at Dipolog City.

DOC.NO.

PAGE NO.

BOOK NO.

SERIES OF 2022

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x
 AFFIDAVIT OF LOSS

I, JEOJESON P. GONZALES, of legal age, Filipino, married, a resident of

Governor’s Village, Estaka, Dipolog City, Zamboanga del Norte, after having
been duly sworn in accordance with law, hereby depose and state:

That I am father of KENTPRINCELEE GONZALES, holder and possessor of

textbook titled 21st Century Mathletes issued by Sta. Isabel Elementary
School, Dipolog City;

That recently my child was processing his papers and scanning thing, we
found out it was lost;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost;

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

foregoing statements and for the purpose of attesting to the loss of the said
textbook.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2022, at Dipolog City.

JEOJESON P. GONZALES
(Affiant)
Driver’s License#J07-17-000690z
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2022, at

Dipolog City.

Doc No. _____

Page No. _____
Book No. ____
Series of 2022
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ELVIRA R. MANDANTES, of legal age, Filipino, married, a resident of Isis,

Polanco, Zamboanga del Norte, after having been duly sworn in accordance
with law, hereby depose and state:

That I am a holder and possessor of UMID card issued by GSIS, ATM card
issued by Metrobank, PRC ID as teacher, Driver’s License, and receipt of X-
ray result of Mario Mandantes;

That recently my wallet containing those identification cards was taken and
thus considered lost;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost;

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

foregoing statements and for the purpose of attesting to the loss of the said
documents and identification cards.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2022, at Dipolog City.

ELVIRA R. MANDANTES
(Affiant)
ID#________________________________
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2022, at

Dipolog City.

Doc No. _____

Page No. _____
Book No. ____
Series of 2022
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, NORBERTO D. PENADOS, of legal age, Filipino, married, a resident of

Poblacion South, Polanco, Zamboanga del Norte, after having been duly
sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of an AFPSLAI Red Passbook issued by

AFPSLAI;

That last week, while I was trying to look for the said AFPSLAI Passbook from
where I kept it, I found out that the AFPSLAI Passbook was lost, and could
not be found;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost;

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

foregoing statements and for the purpose of attesting to the loss of the said
AFPSLAI Passbook, and request the replacement of the said passbook.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2022, at Dipolog City.

NORBERTO D. PENADOS
(Affiant)
Philippine ID#5278-2579-0840-9310
With Photo
SUBSCRIBED AND SWORN to before me this ___ day of _________ 2022, at
Dipolog City.

Doc No. _____

Page No. _____
Book No. ____
Series of 2022

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, IVO M. MANDANTES, of legal age, Filipino, married, a resident of Isis, Polanco,

Zamboanga del Norte after having been duly sworn in accordance with law,
hereby depose and state:

That I am holder and possessor of an official receipt(OR) with Number 5662446D

dated February 7, 2022 issuedby the Clerk of Court of the Regional Trial Court,
Dipolog City.

That in June 2022, I discovered that my said OR was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it
as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
statements and for the purpose of attesting to the loss of the said OR issued by
RTC, Dipolog City.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of June
2022, at Dipolog City.

IVO M. MANDANTES
(Affiant)
PRC ID#0130282
With photo
SUBSCRIBED AND SWORN to before me this ___ day of June 2022, at Dipolog City.

DOC.NO.

PAGE NO.

BOOK NO.

SERIES OF 2022

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ESTERCASIO B. TABUDLONG IIII, of legal age, Filipino, married, a resident

of Poblacion South, Polanco, Zamboanga del Norte, after having been duly
sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of a Passbook issued by Katipunan Bank.-

Dipolog City, Zamboanga del Norte Branch with Account Number
001200034431;

That recently, while I was trying to look for the said passbook from my file
where I kept it, I found out that the passbook was lost, and could not be
found;
That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost;

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

foregoing statements and for the purpose of attesting to the loss of the said
Passbook issued by the said bank, and request the replacement of the said
passbook.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

___ 2022, at Dipolog City.

ESTERCASIO B. TABUDLONG III

(Affiant)
Driver’s License#J01-07-004193
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of ____ 2022, at Dipolog
City.

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, GEOFFREY S. ZAYAS, of legal age, Filipino, married, a resident of Purok

Evergreen, Sta. Filomena, Dipolog City, Zamboanga del Norte after having been
duly sworn in accordance with law, hereby depose and state:

That I am holder and possessor of an official receipt(OR) issued by Land

Transportation Office(LTO) for the renewal of registration of motor vehicle with
Certificate of Registration No.42899876-5. The number of Official receipt was
2169782285.

That in June 2022, I discovered that my said OR was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it
as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
statements and for the purpose of attesting to the loss of the said OR issued by
LTO.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of June
2022, at Dipolog City.

GEOFFREY S. ZAYAS
(Affiant)
Philippine Identification Number 5467-5096-0415-2918
With photo

SUBSCRIBED AND SWORN to before me this ___ day of June 2022, at Dipolog City.

DOC.NO.

PAGE NO.

BOOK NO.

SERIES OF 2022

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS
I, ESTELA A. SANCHEZ of legal age, Filipino, a resident of Dipolog City, Zamboanga del Norte after
having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of an Affidavit of Non-Partition for the Estate of Gavino Abrigana
referencing Bureau of Internal Revenue(BIR)’s eCAR 201700180361 and eCAR201700180362 duly
stamped by the BIR;

That recently, while I was trying to look for my said Affidavit of Non-Partition from my file folder, then
I found out that my Affidavit of Non-Partition was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said Affidavit of Non-Partition and reissuance of the same.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2022, at
Dipolog City.

ESTELA A. SANCHEZ
(Affiant)
TIN ID#120-164-549
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2022, at Dipolog City.

Doc. No.
Page No.
Book No.
Series of 2022
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, MA GEMMA OCAMPO BASTASA, Filipino, of legal age, married, and a

resident of Garcia St., Biasong, Dipolog City, Zamboanga del Norte after
having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of a receipt with P.T. number 47003 issued
by Deposit Pawnshop for a pawned wedding ring with loan date December
13, 2021. That in June 2022, I found out that my receipt was lost, I tried to
locate the receipt but it was really lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
receipt of Deposit Pawnshop.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2022, at Dipolog City.

MA. GEMMA OCAMPO BASTASA

(Affiant)
SSS ID#10-0721328-4
With phot

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2022, at

Dipolog City.

Doc. No.__
Page No.__
Book No.__
Series of 2022
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, VICITACIO J. FELICIA, of legal age, Filipino, single, a resident of Ponot, Jose

Dalman, Zamboanga del Norte after having been duly sworn in accordance with
law, hereby depose and state:

That I am holder and possessor of OSCA Identification(ID) card issued by Office of

Senior Citizen’s Affairs and Voter’s ID card issued by COMELEC.

That recently, I discovered that my said OSCA ID card and Voter’s iD card were
lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it
as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
statements and for the purpose of attesting to the loss of the said OSCA ID card
and Voter’s ID card.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of June
2022, at Dipolog City.

VICITACIO J. FELICIA
(Affiant)
ID#______________________
With photo

SUBSCRIBED AND SWORN to before me this ___ day of June 2022, at Dipolog City.

DOC.NO.

PAGE NO.

BOOK NO.

SERIES OF 2022
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, KIMMY A. PAGADOR, of legal age, Filipino, married, a resident of Upper Turno, Dipolog City,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am an owner of a cellular phone with Sim Card with Number 09684561492 and its Sim Case;

That my said cellular phone with said sim card and case was used in all important transactions;

That recently my said phone was lost;

That it could not be found anymore;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said sim card and sim case and thereafter requesting
replacement of the same.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2022, at
Dipolog City.

KIMMY R. PAGADOR
(Affiant)
Deped ID#1000292-Zamboanga del Norte
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2022, at Dipolog City.

Doc. No.

Page No.

Book No.

Series of 2022
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, FRIMER I. TRUMATA, of legal age, Filipino, single, a resident of Estaka, Dipolog

City, Zamboanga del Norte after having been duly sworn in accordance with law,
hereby depose and state:

That I am holder and possessor of a driver’s license(ID) issued by Land

Transportation Office(LTO) and Official Receipt(OR).

That in June 2022, I discovered that my said driver’s license ID and OR were lost,
and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it
as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
statements and for the purpose of attesting to the loss of the said driver’s license
and OR issued by LTO.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of June
2022, at Dipolog City.

FRIMER I. TRUMATA
(Affiant)
ID#________________________________
With photo

SUBSCRIBED AND SWORN to before me this ___ day of June 2022, at Dipolog City.
DOC.NO.

PAGE NO.

BOOK NO.

SERIES OF 2022

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, FLORA S. COMOYONG- RAMIREZ, of legal age, Filipino, married, a resident of

Purok Lanzones, Betlehem, Polanco, Zamboanga del Norte after having been duly
sworn in accordance with law, hereby depose and state:

That I am holder and possessor of official receipt issued by Rural Bank of Dipolog,
Inc. for the full payment of amortizations on the loan I procured utilizing my parcel
of land covered by Transfer Certificate of Title No.T-58699 situated at Betlehem,
Polanco, Zamboanga del Norte as collateral.

That after I fully paid my obligations, the bank returned the owner’s copy of my
title;

That in June 2022, I tried to annotate the cancellation of mortgage however I

discovered that the full payment official receipt for my amortization was also lost

That despite effort to recover the same but it was naught. Hence, I considered it
as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
statements and for the purpose of attesting to the loss of the said official receipt.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of June
2022, at Dipolog City.
 FLORA S. COMOYONG-RAMIREZ
(Affiant)
OSCA ID#046622-Zamboanga City
With photo

SUBSCRIBED AND SWORN to before me this ___ day of June 2022, at Dipolog City.

DOC.NO.

PAGE NO.

BOOK NO.

SERIES OF 2022

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, REUBEN N. REGENCIA, of legal age, Filipino, married, a resident of

Sta.Filomena, Dipolog City, Zamboanga del Norte after having been duly sworn in
accordance with law, hereby depose and state:

That I am holder and possessor of official receipts issued by Rural Bank of

Dipolog, Inc. for the payment of amortizations on the loan I procured utilizing my
parcel of land covered by Transfer Certificate of Title No.T-10259 situated at Sta.
Filomena, Dipolog City as collateral.

That after I fully paid my obligations, the bank returned the owner’s copy of my
title;

That in June 2022, I tried to annotate the cancellation of mortgage however I

discovered that the official receipts for my amortization were also lost

That despite effort to recover the same but it was naught. Hence, I considered it
as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
statements and for the purpose of attesting to the loss of the said official receipts.
IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of June
2022, at Dipolog City.

REUBEN N. REGENCIA
(Affiant)
Driver’s License#J01-87-006640
With photo

SUBSCRIBED AND SWORN to before me this ___ day of June 2022, at Dipolog City.

DOC.NO.

PAGE NO.

BOOK NO.

SERIES OF 2022

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

We: MARIA DINNA C. VIRAY-PARIÑAS, ROE OMAR M. ICAO, and CARMELITA Y.

BARBASO, all of legal age, all Filipinos, all married, and all with office address of
Dr. Jose Rizal Memorial Hospital, Dapitan City after having been duly sworn in
accordance with law, hereby depose and state:

That we are employees of Dr. Jose Rizal Memorial Hospital, Dapitan City;

That I, Maria Dinna C. Viray-Pariñas, am the Medical Center Chief I of the said
agency and its head of agency; That I, Roe Omar M. Icao, am the Supervising
Administrative Officer, Division Head of Hospital Operations and Patient Support
Service and I, Carmelita Y. Barbaso, am the Administrative Officer V, Section Head
of Materials Management Office;

That we are accountable officers of properties owned by the agency;

That sometime June 8, 2022 at around 10:10 in the evening, a fire incident razed
the conference room of the Administrative Building of Dr. Jose Rizal Memorial
Hospital;

That the following properties were inside the room during the s aid fire incident, to wit:

Ite DESCRIPTION QUANTI UNIT TOTAL REMARKS

m TY PRICE PRICE
No.

1 Airconditioning Unit, 1 unit 142,800 142,800. Installed at

3.0TR, Ceiling Cassette .00 00 the
(Inverter), Daikin, conference
FCF100CVM, Serial Num room
ber: E004443 (Indoor),
E007271 (Outdoor)

2 Airconditioning Unit, 3.0 1 unit 142,800 142,800. Installed at

TR, Ceiling Cassette .00 00 the
(Inverter), Daikin, FCF10 conference
0CVM, Serial Number: room
E005141 (Indoor), E004
568 (Outdoor)

3 Multimedia Projector wit 1 set 17,472. 17,472.0 Use for

h tripod screen, 00 0 meetings,
ACER, DNX1609, SN: M seminars at
RJPA1100P91700BFE59 the
00 conference

4 Video Conference Equip 107,552 107,552. Use for

ment (Polycom only) .75 75 meetings,
seminars at
the
conference

5 Laptop, ASUS, SN: G5N 1 unit 35,180. 35,180.0 Use for

OCV16977322C - 08 8 meetings,
Donation from DOH Cen seminars at
tral Office the
conference

6 LCD Flat Screen Televis 2 43,500. 87,000.0 Use for

ion, 55", 00 0 meetings,
units
SN:18A0012PZ00298, seminars at
18A0012PZ00293 the
conference

7 Sound System 1 unit 16,500. 16,500.0 Use for

 00 0 meetings,
seminars at
the
conference

8 Computer Set, ACER 1 unit 44,966. 44,966.6 Use for

66 6 meetings,
seminars at
the
conference

TOTAL 594,271.
49

That despite effort to recover the same but it was naught. Hence, we considered it
as totally lost;

That as such, we are executing this Affidavit of Loss to attest to the truth of the
foregoing statements and for the purpose of attesting to the loss of the said
property

IN WITNESS WHEREOF, we have hereunto affixed our signatures this ___ day of
June 2022, at Dipolog City.

MARIA DINNA C. VIRAY-PARIÑAS ROE OMAR M. ICAO CARMELITA Y.

BARBASO
(Affiant) (Affiant) (Affiant)

SUBSCRIBED AND SWORN to before me this ___ day of June 2022, at Dipolog City showing
their documents of identification:
Name Valid ID & Number Issuing Office
Maria Dinna C. Viray-
Pariñas
Roe Omar M. Icao
Carmelita Y. Barbaso

DOC.NO.

PAGE NO.

BOOK NO.

SERIES OF 2022
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ANNA MAICA A. BAOY, of legal age, Filipino, single, a resident of Matam,

Katipunan, Zamboanga del Norte after having been duly sworn in accordance
with law, hereby depose and state:

That I am holder and possessor of an identification card being a member of

Philippine National Police(PNP) which was issued by the PNP.

That in June 20, 2022, I discovered that my said PNP ID card was lost, and could
not be found;

That despite effort to recover the same but it was naught. Hence, I considered it
as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
statements and for the purpose of attesting to the loss of the said PNP ID card.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of June
2022, at Dipolog City.

ANNA MAICA A. BAOY

(Affiant)
TIN# 726-245-804
With photo

SUBSCRIBED AND SWORN to before me this ___ day of June 2022, at Dipolog City.

DOC.NO.

PAGE NO.

BOOK NO.

SERIES OF 2022
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, REYNA LUZ Y. GALVEZ, Filipino, of legal age, married, and a resident of

Central, Dipolog City, Zamboanga del Norte after having been duly sworn in
accordance with law, hereby depose and state:

That I am a holder and possessor of an official receipt number 0052-2022-

00195 issued by MLhuillier for a pawned jewelry identified as YG Pendant YG
Necklace in the amount of P17,000.00 pawned on March 17,2022 and
official receipt number 0052-2022-00213 issued by MLhuillier for a pawned
jewelry identified as YG Pendant YG Necklace in the amount of P8,000.00
pawned on March 23,2022

That in June 2022, I found out that my receipts were lost, I tried to locate
the receipt but it was really lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.
As such, I am executing this Affidavit of Loss to attest to the truth of the
foregoing statements and for the purpose of attesting to the loss of the said
official receipts of MLhuillier.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2022, at Dipolog City.

REYNA LUZ Y. GALVEZ

(Affiant)
Driver’s License#J01-19-008209
With phot

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2022, at

Dipolog City.

Doc. No.__
Page No.__
Book No.__
Series of 2022

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, FERNAN B. DAGPIN, of legal age, Filipino, married, a resident of Sicayab,

Dipolog City, Zamboanga del Norte after having been duly sworn in accordance
with law, hereby depose and state:

That I am holder and possessor of a driver’s license(ID) issued by Land

Transportation Office(LTO) and Official Receipt(OR).

That in June 2022, I discovered that my said driver’s license ID and OR were lost,
and could not be found;
That despite effort to recover the same but it was naught. Hence, I considered it
as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
statements and for the purpose of attesting to the loss of the said driver’s license
and OR issued by LTO.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of June
2022, at Dipolog City.

FERNAN B. DAGPIN
(Affiant)
NBI ID NO.D215IFKN98-DR180903
With photo

SUBSCRIBED AND SWORN to before me this ___ day of June 2022, at Dipolog City.

DOC.NO.

PAGE NO.

BOOK NO.

SERIES OF 2022

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS
I, CATHERINE O. ABELLANIDA, of legal age, Filipino, single, a resident of Poblacion
North, Polanco, Zamboanga del Norte after having been duly sworn in
accordance with law, hereby depose and state:

That I am holder and possessor of an Official Receipt(OR) with number

2031462344 issued by Land Transportation Office(LTO) for the renewal of
registration of my motor vehicle with Plate No.574JOB;

That in June 2022, I discovered that my said OR was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it
as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
statements and for the purpose of attesting to the loss of the said OR issued by
LTO.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of June
2022, at Dipolog City.

CATHERINE O. ABELLANIDA
(Affiant)
Driver’s License#J01-20-005157
With photo

SUBSCRIBED AND SWORN to before me this ___ day of June 2022, at Dipolog City.

DOC.NO.

PAGE NO.

BOOK NO.

SERIES OF 2022
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, HERLENE D. TOLENTINO, of legal age, Filipino, married, a resident of Minaog,

Dipolog City, Zamboanga del Norte after having been duly sworn in accordance
with law, hereby depose and state:

That I am holder and possessor of a driver’s license(ID) issued by Land

Transportation Office(LTO) and Official Receipt(OR).

That in June 2022, I discovered that my said driver’s license ID and OR were lost,
and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it
as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
statements and for the purpose of attesting to the loss of the said driver’s license
and OR issued by LTO.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of June
2022, at Dipolog City.

HERLENE D. TOLENTINO
(Affiant)
PNP ID#20G2700262
With photo

SUBSCRIBED AND SWORN to before me this ___ day of June 2022, at Dipolog City.

DOC.NO.

PAGE NO.

BOOK NO.

SERIES OF 2022
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, JEREMIAS C. CAGBABANUA, of legal age, Filipino, married, a resident of

Barangay Aseniero, Dapitan City, Zamboanga del Norte, after having been
duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of a Policy Contract, issued by Armed

Forces and Police Mutual Benefits Association, Inc.(AFPMBAI);

That in June 2022, while I was trying to look for the said Policy Contract from
my file where I kept it, I found out that the certification was lost, and could
not be found;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost;

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

foregoing statements and for the purpose of attesting to the loss of the said
Policy Contract issued by AFPMBAI.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2022, at Dipolog City.

JEREMIAS G. CAGBABANUA
(Affiant)
Driver’s License#J01-20-008518
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2022, at

Dipolog City.

DOC. NO.

PAGE NO.
BOOK NO.

SERIES OF 2022

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ELAINE MARIE ENAO SANTANDER, of legal age, Filipino, married, a resident of VCH, Obay, Polanco,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am holder and possessor of a Professional Regulation Commission(PRC) Identification card with
number 0401868 as Nurse;

That I discovered that my PRC license was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said PRC license.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2022, at
Dipolog City.

ELAINE MARIE ENAO SANTANDER

(Affiant)
PRC ID#0401868.
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2022, at Dipolog City.

Doc. No.

Page No.
Book No.

Series of 2022

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, JAYPAUL FERRER ANTIQUINA, of legal age, Filipino, single, a resident of Imelda, Labason,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am holder and possessor of DIPLOMA as graduate of a course-2 year Information Technology at
Dipolog School of Fisheries, Dipolog City;

That I discovered that the original copy of my Diploma was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said Diploma.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2022, at
Dipolog City.

JAYPAUL F. ANTIQUINA
(Affiant)
UMID ID#CRN-0111-2266314-6
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2022, at Dipolog City.

Doc. No.
Page No.

Book No.

Series of 2022

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS
I, EXPEDITO R. OLMOGUES, of legal age, Filipino, a resident of 016 Del Pilar St.,
Dipolog City, Zamboanga del Norte after having been duly sworn in accordance
with law, hereby depose and state:

That I am holder and possessor of a driver’s license(ID) issued by Land

Transportation Office(LTO) and Official Receipt(OR).

That in June 2022, I discovered that my said driver’s license ID and OR were lost,
and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it
as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
statements and for the purpose of attesting to the loss of the said driver’s license
and OR issued by LTO.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of June
2022, at Dipolog City.

EXPEDITO R. OLMOGUES
(Affiant)
Driver’s License#J01-67-002300
With photo

SUBSCRIBED AND SWORN to before me this ___ day of June 2022, at Dipolog City.

DOC.NO.

PAGE NO.

BOOK NO.

SERIES OF 2022
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, RINGO CARREON LIM, of legal age, Filipino, a resident of Crisostomo Ibarra St.,
Dawo, Dapitan City, Zamboanga del Norte after having been duly sworn in
accordance with law, hereby depose and state:

That I am holder and possessor of a driver’s license(ID) issued by Land

Transportation Office(LTO) and Official Receipt(OR).

That in June 2022, I discovered that my said driver’s license ID and OR were lost,
and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it
as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
statements and for the purpose of attesting to the loss of the said driver’s license
and OR issued by LTO.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of June
2022, at Dipolog City.

RINGO CARREON LIM

(Affiant)
Driver’s License#J01-05-003469
With photo

SUBSCRIBED AND SWORN to before me this ___ day of June 2022, at Dipolog City.

DOC.NO.

PAGE NO.

BOOK NO.

SERIES OF 2022
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF COMPLETION

I, KAREN JANE E. MONDEJAR, of legal age, Filipino, married, a resident of Galas, Dipolog City,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am applicant of loan at Pag-ibig for purpose of construction of residential building at a parcel of
land more particularly described as follows:

“A parcel of land covered by Transfer Certificate of Title No.128-2021000554 situated at Gulayon,

Dipolog City”

That the residential building constructed and built over the said parcel of land is completed and finished
in accordance with the plans approved by government agencies.

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

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of June 2022, at Dipolog
City.

KAREN JANE E. MONDEJAR

(Affiant)
Driver’s License#J01-20-006566
With photo

SUBSCRIBED AND SWORN to before me this ___ day of June 2022, at Dipolog City.

DOC.NO.

PAGE NO.

BOOK NO.

SERIES OF 2022
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, FREDERIC PAGHASIAN VELASCO, of legal age, Filipino, single, a resident of 516

Lapu-lapu St corner Rizal Ave Ext., Estaka, Dipolog City, Zamboanga del Norte
after having been duly sworn in accordance with law, hereby depose and state:

That I am holder and possessor of Tax Identification Number(TIN) card and

Unified Multipurpose Identification(UMID) cards under my name;

That on June 12, 2022, my said documents were lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it
as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
statements and for the purpose of attesting to the loss of the said TIN and UMID
cards.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of June
2022, at Dipolog City.

FREDERIC PAGHASIAN VELASCO

(Affiant)
ID#___________________
With photo

SUBSCRIBED AND SWORN to before me this ___ day of June 2022, at Dipolog City.

DOC.NO.

PAGE NO.

BOOK NO.

SERIES OF 2022
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ESTRELLITA CUENCA AGOSILA, of legal age, Filipino, widow, a resident of Estaka,

Dipolog City, Zamboanga del Norte after having been duly sworn in accordance
with law, hereby depose and state:

That I am holder and possessor of official receipts on the payments of

amortization of loan using the parcel of land covered by Transfer Certificate of
Title No.T-15006, situated at Estaka, Dipolog City as collateral with mortgagee
Rural Bank of Dipolog, Inc.

That on June 13, 2022, I discovered that the official receipts of payments of
amortization issued by Rural Bank of Dipolog, Inc. were lost, and could not be
found;

That despite effort to recover the same but it was naught. Hence, I considered it
as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
statements and for the purpose of attesting to the loss of the said receipts.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of June
2022, at Dipolog City.

ESTRELLITA CUNCA AGOSILA

(Affiant)
UMID ID#CRN-021-1116-1453-3
With photo

SUBSCRIBED AND SWORN to before me this ___ day of June 2022, at Dipolog City.

DOC.NO.

PAGE NO.

BOOK NO.

SERIES OF 2022
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ALEX S. PAGHACIAN, of legal age, Filipino, married, a resident of Minaog,

Dipolog City, Zamboanga del Norte after having been duly sworn in accordance
with law, hereby depose and state:

That I am holder and possessor of a ATM card as PNP Retiree because I am retired
member of PNP, Philhealth ID and Voters ID of my spouse Yolanda Eguia
Paghacian

That on June 11 2022, the wallet of my spouse containing those documents was
lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it
as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
statements and for the purpose of attesting to the loss of the said PNP Retiree’s
ATM card89ij, Philhealth ID of my spouse, and Voters ID of my spouse.
IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of June
2022, at Dipolog City.

ALEX S. PAGHACIAN
(Affiant)
PNP Retiree ID#PRO9-7RI91039826783
With photo

SUBSCRIBED AND SWORN to before me this ___ day of June 2022, at Dipolog City.

DOC.NO.

PAGE NO.

BOOK NO.

SERIES OF 2022

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, RUEL N. ESPERANZA,JR, of legal age, Filipino, single, a resident of Dangi,

Polanco, Zamboanga del Norte after having been duly sworn in accordance with
law, hereby depose and state:

That I am holder and possessor of a driver’s license(ID) issued by Land

Transportation Office(LTO) and Official Receipt(OR).
That in May 30 2022, I discovered that my said driver’s license ID and OR were
lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it
as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
statements and for the purpose of attesting to the loss of the said driver’s license
and OR issued by LTO.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of June
2022, at Dipolog City.

RUEL N. ESPERANZA,JR
(Affiant)
ID#_____________________
With photo

SUBSCRIBED AND SWORN to before me this ___ day of June 2022, at Dipolog City.

DOC.NO.

PAGE NO.

BOOK NO.

SERIES OF 2022

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF JUSTIFICATION

I, MARY JOY D. DUHAYLUNGSOD, of legal age, Filipino, single, a resident of Silano,

Pinan, Zamboanga del Norte after having been duly sworn in accordance with
law, hereby depose and state:
That I am personnel-in-charge with remitting contribution to the Social Security
System(SSS) of employer Rayzel D. Calape, MD;

That however upon remittance, I mistakenly entered my SSS number 1011819962

instead of my employer’s SSS number 10-0747566-6-000;

That this affidavit is executed to the attest to the mistake in entering the SSS
number which is not malicious and not intentionally done;

That this is further executed to correct the error committed;

That I am attesting the truthfulness of above statement.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of June
2022, at Dipolog City.

MARY JOY D. DUHAYLUNGSOD

(Affiant)
TIN#715-913-482
With photo

SUBSCRIBED AND SWORN to before me this ___ day of June 2022, at Dipolog City.

DOC.NO.

PAGE NO.

BOOK NO.

SERIES OF 2022

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, JUDY ANN E. BELLO, of legal age, Filipino, married to Henry Tomas Bello, a
resident of Madison County Home, Dicayas, Dipolog City, Zamboanga del Norte
after having been duly sworn in accordance with law, hereby depose and state:
That I am holder and possessor of a original copy of Extrajudicial Settlement of
Estate notarized by Atty. Nelson R. Ageas under Doc. No.2017, Page No.61, Book
No.XLIV, Series of 2021 with stamp by BIR and eCAR for the taxes on the said
transaction;

That I came possession of the said documents because I purchased the land
subject in the said extrajudicial pursuant to deed notarized by Atty. Mayrose P.
Santillana-Castillon under Doc. No.45, Page No.10, Book No.III, Series of 2021;

That on April 30, 2022, I discovered that my said documents were lost, and could
not be found;

That despite effort to recover the same but it was naught. Hence, I considered it
as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
statements and for the purpose of attesting to the loss of the said documents.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of June
2022, at Dipolog City.

JUDY ANN E. BELLO

(Affiant)
IID#_________________________-
With photo

SUBSCRIBED AND SWORN to before me this ___ day of June 2022, at Dipolog City.

DOC.NO.

PAGE NO.

BOOK NO.

SERIES OF 2022
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, JOSEPHUS GLENN M. GARATE, of legal age, Filipino, a resident of Sta.

Isabel,Dipolog City, Zamboanga del Norte after having been duly sworn in
accordance with law, hereby depose and state:

That I was a holder and possessor of a Landbank Check with Number 0002626756
issued by Local Government Unit of Jose Dalman, Zamboanga del Norte with an
amount of P47,321.44.

That it was issued to payee PERMAHEAL ENTERPRISE, which I owned;

That on March 28, 2022, I was informed that said check was lost, and could not be
found;

That despite effort to recover the same but it was naught. Hence, I considered it
as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
statements and for the purpose of attesting to the loss of the said check .

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2022, at Dipolog City.

JOSEPHUS GLENN M. GARATE

(Affiant)
Passport#P4734290B
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2022, at Dipolog
City.

DOC.NO.

PAGE NO.

BOOK NO.

SERIES OF 2022
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, MARIFE C. ENERO, Filipino, of legal age, married, and a resident of

Olingan, Dipolog City, Zamboanga del Norte after having been duly sworn
in accordance with law, hereby depose and state:

That I am a holder and possessor of an official receipt issued by MLhuillier

for a pawned jewelry identified as Earring PR YG DEF 18K 1-10g with Receipt
No. 0438-2022-00573 in the amount of P2,500.00 pawned on April 18,2022.

That in May, 2022, I found out that my receipt was lost, I tried to locate the
receipt but it was really lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
official receipt of MLhuillier.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2022, at Dipolog City.

MARIFE C. ENERO
(Affiant)
Driver’s License#J01-04-000866
With phot

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2022, at

Dipolog City.

Doc. No.__
Page No.__
Book No.__
Series of 2022
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, JUDELYN R. ENTERO, of legal age, Filipino, married, resident of Polo, Dapitan City, Zamboanga del Norte
after having been duly sworn in accordance with law, hereby depose and state:

That I am the attorney-in-fact of Roselieto R. Jauculan, owner of a parcel of land, more particularly described as
follows:

A parcel of land known as Lot No.451, covered by Original Certificate of Title No.P-12921 situated at Calican,
Pinan, Zamboanga del Norte, containing an area of 9,360 square meters issued by the Register of Deeds for
Zamboanga del Norte.

That my principal became the owner of the said parcel of land by virtue of Deed of Extra-judicial Settlement
and Partition of the Estate of Felix C. Jauculan with Waiver of Rights notarized by Michael Alan Ranillo of
Dipolog City per notarial register with Doc. No.2807, Page No.93, Book No.110, Series of 2009;

That my principal had lost the said owner’s copy of said parcel of land ;

That despite effort to recover the same but it was naught.

That I/he considered it as totally lost.

That I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for the purpose
of attesting to the loss of the said owner’s copy of Original Certificate of Title No.P-12921.

IN WITNESS WHEREOF, I have hereunto affixed my signature this __th day of _______ 2022, at Dipolog
City.

JUDELYN R. ENTERO

(Affiant)

Voters ID#7201-0131A-J2568JRE20001-5

SUBSCRIBED AND SWORN to before me this ___th day of ________ 2022, at Dipolog City.

DOC.NO. ______

PAGE NO.___

BOOK NO.___

SERIES OF 2022
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, CHARITO S. SALIENTE, of legal age, Filipino, married, a resident of Prk Dancing

Lady,Gulayon, Dipolog City after having been duly sworn in accordance with law,
hereby depose and state:

That I am the mother of Charity Faith Sularte Saliente, a student of Andres

Bonifacio College(ABC), Dipolog City;

That I paid for the tuition fees of my said child;

That hence I was holder and possessor of Official Receipt Nos. 0096080, 0093042
and 0092322 issued by ABC for her tuition fees.

That on May 20, 2022, I discovered that the said official receipts were lost, and
could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it
as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
statements and for the purpose of attesting to the loss of the said official receipts.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2022, at Dipolog City.

CHARITO S. SALIENTE
(Affiant)
Postal ID#PRNM83160338741P
With photo
SUBSCRIBED AND SWORN to before me this ___ day of _________ 2022, at Dipolog
City.

DOC.NO.

PAGE NO.

BOOK NO.

SERIES OF 2022

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, JASON Y. GARINGO, of legal age, Filipino, single, a resident of Gulayon, Dipolog

City after having been duly sworn in accordance with law, hereby depose and
state:

That I am an employee of Pryce Gases, Inc.

That I am holder and possessor of a Sales Invoice Nos. 10850-10900 issued by my

employer.

That on May 14, 2022, I discovered that the said sales invoices were lost, and
could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it
as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
statements and for the purpose of attesting to the loss of the said sales invoices.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2022, at Dipolog City.

JASON Y. GARINGO
 (Affiant)
Drivers License#N25-20-056788
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2022, at Dipolog
City.

DOC.NO.

PAGE NO.

BOOK NO.

SERIES OF 2022

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, MARY GRACE M. PUSTA, of legal age, Filipino, single/married, a resident of Dipolog City, Zamboanga
del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am an owner of a cellular phone Oppo Reno 4 with Sim Card Number 09128115503;

That my said cellular phone with said sim card was bound and logged in all of my online banking
transactions;

That recently my said phone was lost;

That it could not be found anymore;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said sim card and thereafter requesting replacement of the
same.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2022, at
Dipolog City.

MARY GRACE M. PUSTA

(Affiant)
PRC ID#0829858
Valid until 07/20/2023
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2022, at Dipolog City.

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ALEXANDER T. ESPINAS, of legal age, Filipino, married, a resident of Aseniero,

Dapitan City, Zamboanga del Norte after having been duly sworn in accordance
with law, hereby depose and state:

That I am holder and possessor of a Driver’s License issued by LTO.

That in year 2014, I discovered that my said LTO driver’s license was lost, and
could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it
as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
statements and for the purpose of attesting to the loss of the said Driver’s License
issued by LTO.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of May
2022, at Dipolog City.

ALEXANDER T. ESPINAS
(Affiant)
ID#_________________________-
With photo

SUBSCRIBED AND SWORN to before me this ___ day of May 2022, at Dipolog City.

DOC.NO.

PAGE NO.

BOOK NO.

SERIES OF 2022

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS
I, ALJUN P. PACAMALAN, of legal age, Filipino, single, a resident of Olingan,
Dipolog City, Zamboanga del Norte, after having been duly sworn in
accordance with law, hereby depose and state:

That I am a holder and possessor of a National Certificate known as NC III

for Visual Graphic Design III issued by TESDA;

That in May 2022, while I was trying to look for the said certificate from my
file where I kept it, I found out that the document was lost, and could not be
found;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost;

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

foregoing statements and for the purpose of attesting to the loss of the said
certificate.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

May 2022, at Dipolog City.

ALJUN P. PACAMALAN
(Affiant)
DSF School ID#VGD-18-136
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of May 2022, at Dipolog
City.
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, CLIFFORD Q. SARCENO, of legal age, Filipino, single, a resident of Sta.Filomena, Dipolog City,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of a Talk’n Text Sim card with number 09306764922;

That my said Talk’n Text Sim card was missing ;

That it could not be found anymore;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said sim card and thereafter requesting replacement of the
same.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2022, at
Dipolog City.

CLIFFORD Q. SARCENO
(Affiant)
UMID ID#CRN-0111-4460700-9
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2022, at Dipolog City.
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, JOSE RAMIL C. VELASCO, of legal age, Filipino, married to Lorena Dangcalan, resident of P. Zamora St
Ext., Dipolog City, Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose
and state:

That I am the son of late Leodegaria C. Velasco, registered owner of a parcel of land, more particularly
described as follows:

A parcel of land known as Lot No.649, covered by Transfer Certificate of Title No.T-11639 situated at Sipaloc,
Sibutad, Zamboanga del Norte, containing an area of 40,232 square meters issued by the Register of Deeds for
Zamboanga del Norte.

That on April 5, 2022 after I secure the the owner’s copy of the title of the said parcel of land from the bank and
was placed inside a bag but it was lost while my daughter was traveling;

That despite effort to recover the same but it was naught.

That I considered it as totally lost.

That I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for the purpose
of attesting to the loss of the said owner’s copy of Transfer Certificate of Title No.T-11639.

IN WITNESS WHEREOF, I have hereunto affixed my signature this __th day of _______ 2022, at Dipolog
City.

IGNACIA JALAMPANGAN ICAO

(Affiant)

ID#______________________

SUBSCRIBED AND SWORN to before me this ___th day of ________ 2022, at Dipolog City.

DOC.NO. ______

PAGE NO.___

BOOK NO.___
SERIES OF 2022

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, MARIO B. VICERA, of legal age, Filipino, a resident of Estaka, Dipolog City, Zamboanga del Norte
after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of the original copy Motorized Tricycle Operator’s Permit(MTOP)
issued by Local Government of Dipolog City with MTOP DPLG NO. 2021-1172 registered under my
name.

That in May 2022 while I was trying to look for the MTOP of my tricycle, I found out that the it was
lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said MTOP.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2022, at
Dipolog City.

MARIO B. VICERA
(Affiant)
ID#__________________________
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2022, at Dipolog City.

Doc. No
Page No
Book No
Series of 2022
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, MINETTE C. OGOC-ANSAL, of legal age, Filipino, married, a resident of

Lalawan, Dicayas, Dipolog CIty, Zamboanga del Norte after having been
duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of a Philippine Passport issued by the

Department of Foreign Affairs. That the passport was issued when I was still
single and carried the name Minette C. Ogoc;

That on May 4, 2022, I found out that my said passport was missing;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
passport.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2022, at Dipolog City.

MINETTE C. OGOC-ANSAL
(Affiant)
PRC ID#1257498
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2022, at

Dipolog City.
Doc. No.___

Page No.___

Book No.___

Series of 2022

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, GRACE C. BADLON, of legal age, Filipino, married, a resident of East Poblacion, Manukan,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am the mother of Ian Clifford C. Badlon, holder and possessor of his DIPLOMA as graduate of a
course Bachelor of Science in Accountancy at Saint Vincent’s College Incorporated, DIpolog City. That
my child left me the abovesaid documents for safekeeping

That on May 4, 2021, I discovered that folder containing the said documents was lost, and could not
be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said Diploma and other documents.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2022, at
Dipolog City.

GRACE C. BADLON
(Affiant)
Manukan NHS Employee ID#MTCHR1-570024-2002
With photo
SUBSCRIBED AND SWORN to before me this ___ day of _________ 2022, at Dipolog City.

Doc. No.

Page No.

Book No.

Series of 2022

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ROLLY S. FULGUERAS, of legal age, Filipino, married, a resident of Poblacion Alto, Sergio Osmena,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am the holder and possessor of Driver’s License, OR/CR of my motorcycle with Engine
No.1P52FMIJ1820493 and CR No.335278624;

That on April 6, 2022, our house was ravaged by fire together with the said documents;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;
As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said Driver’s License and OR/CR of my motorcycle.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2022, at
Dipolog City.

ROLLY S. FULGUERAS
(Affiant)
PWD ID#09-72-14-023-241
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2022, at Dipolog City.

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS
I, HAZEL JACA VILLARINO, of legal age, Filipino, married, a resident of
Poblacion South, Polanco, Zamboanga del Norte, after having been duly
sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of a Passbook issued by 1 st Valley Bank,

Inc.-Dipolog City, Zamboanga del Norte Branch with Account Number 015-
56-01568-2;

That in April 2022, while I was trying to look for the said passbook from my
file where I kept it, I found out that the passbook was lost, and could not be
found;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost;

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

foregoing statements and for the purpose of attesting to the loss of the said
Passbook issued by the said bank, and request the replacement of the said
passbook.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

April 2022, at Dipolog City.

HAZEL JACA VILLARINO

(Affiant)
Driver’s License#J01-07-000640
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of April 2022, at

Dipolog City.
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, EQUILINA CALIBUGAR ALIAWAN, of legal age, Filipino, single, a resident of

Minaog, Dipolog City, Zamboanga del Norte after having been duly sworn in
accordance with law, hereby depose and state:

That I am holder and possessor of a Driver’s License issued by LTO, Tax

Identification Card issued by BIR, School Identification card of Saint Vincent’s
College and Dipolog Medical College.

That in April 2022, I discovered that my bag containing those identification cards
was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it
as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
statements and for the purpose of attesting to the loss of the said Driver’s License
issued by LTO, Tax Identification Card issued by BIR, School Identification card of
Saint Vincent’s College and Dipolog Medical College

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of April
2022, at Dipolog City.

EQUILINA CALIBUGAR ALIAWAN

(Affiant)
Drivers License#J01-20-002237
With photo

SUBSCRIBED AND SWORN to before me this ___ day of April 2022, at Dipolog City.

DOC.NO.

PAGE NO.

BOOK NO.

SERIES OF 2022
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, JANET C. PADASIG, of legal age, Filipino, married, a resident of Estaka, Dipolog

City, Zamboanga del Norte after having been duly sworn in accordance with law,
hereby depose and state:

That I am holder and possessor of a receipt issued by Imperial Appliance Plaza-

Dipolog City Branch dated August 15, 2021 and with receipt number CR144458.

That in April 2022, I discovered that my said receipt was lost, and could not be
found;

That despite effort to recover the same but it was naught. Hence, I considered it
as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
statements and for the purpose of attesting to the loss of the said receipt.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of April
2022, at Dipolog City.

JANET C. PADASIG
(Affiant)
DILG ID#2018-068-Estaka, Dipolog City
With photo

SUBSCRIBED AND SWORN to before me this ___ day of April 2022, at Dipolog City.

DOC.NO.

PAGE NO.

BOOK NO.

SERIES OF 2022
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, MEL KIRBY R. ROJAS, of legal age, Filipino, single, a resident of Turno, Dipolog
City, Zamboanga del Norte after having been duly sworn in accordance with law,
hereby depose and state:

That I am holder and possessor of a driver’s license(ID) with No.G02-13-004168

issued by Land Transportation Office(LTO) and Official Receipt(OR).

That in April 2022, I discovered that my said driver’s license ID and OR were lost,
and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it
as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
statements and for the purpose of attesting to the loss of the said driver’s license
and OR issued by LTO.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of April
2022, at Dipolog City.

MEL KIRBY R. ROJAS

(Affiant)
TIN#736-095-886
With photo

SUBSCRIBED AND SWORN to before me this ___ day of April 2022, at Dipolog City.

DOC.NO.

PAGE NO.

BOOK NO.
SERIES OF 2022

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ROXAN S. TESTA, of legal age, Filipino, married, a resident of

Mauswagon, La Libertad, Zamboanga del Norte, after having been duly
sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of a Passbook issued by 1 st Valley Bank,

Inc.-Dipolog City, Zamboanga del Norte Branch with Account Number 55-
06158-1;

That in April 2022, while I was trying to look for the said passbook from my
file where I kept it, I found out that the passbook was lost, and could not be
found;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost;

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

foregoing statements and for the purpose of attesting to the loss of the said
Passbook issued by the said bank, and request the replacement of the said
passbook.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

April 2022, at Dipolog City.

ROXAN S. TESTA
 (Affiant)
Drivers License#J01-18-005086
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of April 2022, at

Dipolog City.

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, PERFECTO LUAB, of legal age, Filipino, a resident of Leon Postigo, Zamboanga del Norte after having
been duly sworn in accordance with law, hereby depose and state:

That I am the vendor’s spouse/holder and possessor of an original BIR stamped Deed of Absolute Sale
notarized by Atty. Dan C. Santos under Doc. No.597, Page No. 26, Book No. VI, Series of 2017. That
however after it was stamped by the BIR, the said original copy of the Deed of Absolute Sale duly
stamped by BIR was lost.

That I tried to locate the said document, but it could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said BIR stamped Deed of Absolute Sale.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2022, at
Dipolog City.

PERFECTO LUAB
(Affiant)
 ID#________________________
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2022, at Dipolog City.

Doc. No.

Page No

Book No

Series of 2022

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, RONIE MARK T. ALETA, of legal age, Filipino, single, a resident of Gov. Village, Estaka, Dipolog City,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of a Smart Sim card with number 09618270783;

That my cellular phone containing the said Smart Sim card was missing ;

That it could not be found anymore;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said sim card and thereafter requesting replacement of the
same.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2022, at
Dipolog City.
 RONIE MARK T. ALETA
(Affiant)
UMID ID#CRN-0111-3381329-9
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2022, at Dipolog City.

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, JENNIFER C. BAHI-AN, of legal age, Filipino, single, a resident of Purok Orchid, Sicayab,
Dipolog City, Zamboanga del Norte after having been duly sworn in accordance with law,
hereby depose and state:

That I am a holder/possessor of receipt of pawned jewelry issued by Oval Pawnshop Dipolog

Branch with PT#4828. The jewelry is Ring w/ GD 0.13ct pcs. And RD teardrop des YG ital. 14K
6g;

That sometime April 2022, while I was trying to locate the said receipt I could not find it
because it was lost and could not be fwkhound;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;
As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements
and for the purpose of attesting to the loss of the said receipt.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2022,
at Dipolog City.

JENNIFER C. BAHI-AN
(Affiant)
Driver’s License#J01-16-000491
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2022, at Dipolog City.

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS
I, KENNETH M. ALVAR, of legal age, Filipino, married, a resident of Ortega
St cor. Gen Luna, Estaka, Dipolog City, Zamboanga del Norte, after having
been duly sworn in accordance with law, hereby depose and state:

That I am the keeper of the Business Permit and Business Plate of Maples
Boutique, located at Ortega St.Estaka, Dipolog City, registered under the
name of my wife Ma. Cindy O. ALvar;

That last week, while I was trying to look for the said business permit and
plate from where I kept it, I found out that the business plate and permit
were lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost;

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

foregoing statements and for the purpose of attesting to the loss of the said
business permit and plate.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2022, at Dipolog City.

KENNETH M. ALVAR
(Affiant)
Driver’s License#J01-02-039069
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2022, at

Dipolog City.

Doc No. _____

Page No. _____
Book No. ____
Series of 2022
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, MA. CRISTINA H. MANDALUNES, of legal age, Filipino, married, a resident of

Mias, Katipunan, Zamboanga del Norte after having been duly sworn in
accordance with law, hereby depose and state:

That I am holder and possessor of a driver’s license(ID) issued by Land

Transportation Office(LTO) and Official Receipt(OR).

That in March 2022, I discovered that my said driver’s license ID and OR were
lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it
as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
statements and for the purpose of attesting to the loss of the said driver’s license
and OR issued by LTO.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of April
2022, at Dipolog City.

MA. CRISTINA H. MANDALUNES

(Affiant)
Philhealth ID#19-000811989-2
With photo

SUBSCRIBED AND SWORN to before me this ___ day of April 2022, at Dipolog City.

DOC.NO.

PAGE NO.

BOOK NO.

SERIES OF 2022
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, IGNACIA JALAMPANGAN ICAO, of legal age, Filipino, widow, resident of Purok 5, Marapong, Sibutad,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am the daughter of Nicolas Jalampangan, registered owner of a parcel of land, more particularly
described as follows:

A parcel of land known as Lot No.649, covered by Transfer Certificate of Title No.T-11639 situated at Sipaloc,
Sibutad, Zamboanga del Norte, containing an area of 40,232 square meters issued by the Register of Deeds for
Zamboanga del Norte.

That on April 5, 2022 after I secure the the owner’s copy of the title of the said parcel of land from the bank and
was placed inside a bag but it was lost while my daughter was traveling;

That despite effort to recover the same but it was naught.

That I considered it as totally lost.

That I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for the purpose
of attesting to the loss of the said owner’s copy of Transfer Certificate of Title No.T-11639.

IN WITNESS WHEREOF, I have hereunto affixed my signature this __th day of _______ 2022, at Dipolog
City.

IGNACIA JALAMPANGAN ICAO

(Affiant)

ID#______________________

SUBSCRIBED AND SWORN to before me this ___th day of ________ 2022, at Dipolog City.

DOC.NO. ______

PAGE NO.___

BOOK NO.___

SERIES OF 2022
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ODETTE MITZI O. OCHOTORENA, of legal age, Filipino, married, a resident

of Olingan, Zamboanga del Norte, after having been duly sworn in
accordance with law, hereby depose and state:

That I am a holder and possessor of a Passbook issued by 1 st Valley Bank,

Inc.-Manukan, Zamboanga del Norte Branch with Account Number 026-51-
00249-8;

That in April 2022, while I was trying to look for the said passbook from my
file where I kept it, I found out that the passbook was lost, and could not be
found;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost;

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

foregoing statements and for the purpose of attesting to the loss of the said
Passbook issued by the said bank, and request the replacement of the said
passbook.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

April 2022, at Dipolog City.

ODETTE MITZI O. OCHOTORENA

(Affiant)
DepEd Employee ID#0040149
With Photo
SUBSCRIBED AND SWORN to before me this ___ day of April 2022, at
Dipolog City.

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ROSALIE MILDED M. ALVAR, of legal age, Filipino, single, a resident of

Ortega St cor. Gen Luna, Estaka, Dipolog City, Zamboanga del Norte, after
having been duly sworn in accordance with law, hereby depose and state:

That I am the keeper of the Business Permit of Quick Pick Mini-Mart, located
at Ortega St.Estaka, Dipolog City;

That last week, while I was trying to look for the said business permit from
where I kept it, I found out that the business plate was lost, and could not
be found;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost;

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

foregoing statements and for the purpose of attesting to the loss of the said
business permit.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2022, at Dipolog City.
 ROSALIE MILDRED M. ALVAR
(Affiant)
Driver’s License#J01-07-001331
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2022, at

Dipolog City.

Doc No. _____

Page No. _____
Book No. ____
Series of 2022

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, JUNE JOYCE J. VILLALUZ, of legal age, Filipino, married, a resident of Iligan City,
Lanao del Norte after having been duly sworn in accordance with law, hereby
depose and state:

That I am holder and possessor of a driver’s license(ID) issued by Land

Transportation Office(LTO).
That in March 2022, I discovered that my said driver’s license ID was lost, and
could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it
as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
statements and for the purpose of attesting to the loss of the said driver’s license
issued by LTO.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of April
2022, at Dipolog City.

JUNE JOYCE J. VILLALUZ

(Affiant)
Phil.Passport#P3979308A
With photo

SUBSCRIBED AND SWORN to before me this ___ day of April 2022, at Dipolog City.

DOC.NO.

PAGE NO.

BOOK NO.

SERIES OF 2022

1Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS
I, EFREN N. ARRO, of legal age, Filipino, married, a resident of Purok 1,
Lugdungan, Dipolog City, Zamboanga del Norte after having been duly sworn in
accordance with law, hereby depose and state:

That I am holder and possessor of a driver’s license issued by Land Transportation

Office(LTO).

That on March 5 2022, I discovered that my wallet containing my said driver’s

license ID was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it
as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
statements and for the purpose of attesting to the loss of the said driver’s license
issued by LTO.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of March
2022, at Dipolog City.

EFREN N. ARRO
(Affiant)
TIN#160-625-984
With photo

SUBSCRIBED AND SWORN to before me this ___ day of March 2022, at Dipolog
City.

DOC.NO.

PAGE NO.

BOOK NO.

SERIES OF 2022

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, JUNE JOYCE J. VILLALUZ, of legal age, Filipino, married, a resident of Iligan City,
Lanao del Norte after having been duly sworn in accordance with law, hereby
depose and state:

That I am holder and possessor of a driver’s license(ID) issued by Land

Transportation Office(LTO).

That in March 2022, I discovered that my said driver’s license ID was lost, and
could not be found;
That despite effort to recover the same but it was naught. Hence, I considered it
as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
statements and for the purpose of attesting to the loss of the said driver’s license
issued by LTO.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of April
2022, at Dipolog City.

JUNE JOYCE J. VILLALUZ

(Affiant)
Phil.Passport#P3979308A
With photo

SUBSCRIBED AND SWORN to before me this ___ day of April 2022, at Dipolog City.

DOC.NO.

PAGE NO.

BOOK NO.

SERIES OF 2022
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, EARL MAVIN BUSALLA TABUDLONG, of legal age, Filipino, a resident of Poblacion South,
Polanco, Zamboanga del Norte after having been duly sworn in accordance with law, hereby
depose and state:

That I am a holder/possessor of Certificate of Full Payment issued by St. Peter Lifeplan, Inc for
my life plan with Contract No.L14935070E;

That sometime March 2022, I discovered that the said certificate was lost and I tried to locate
the said certificate but I could not find it;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements
and for the purpose of attesting to the loss of the said certificate of full payment.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ____ day of __________
2022, at Dipolog City.

EARL MAVIN B. TABUDLONG

(Affiant)
ID#__________________________
With photo

SUBSCRIBED AND SWORN to before me this ___ day of ________ 2022, at Dipolog City.
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, MA. SANDRA B. PAGENTE, of legal age, Filipino, widow, a resident of

Sunset Blvd., Sta. Cruz, Dapitan City, Zamboanga del Norte, after having
been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of two(2) AFPSLAI Passbook issued by

AFPSLAI under the name of my late spouse F/CINSP EDGAR DELGADO
PAGENTE;

That last week, while I was trying to look for the said AFPSLAI Passbooks
from where I kept it, I found out that the AFPSLAI Passbooks were lost, and
could not be found;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost;
As such, I am executing this Affidavit of Loss to attest to the truth of the
foregoing statements and for the purpose of attesting to the loss of the said
AFPSLAI Passbooks, and request the replacement of the said passbook.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2022, at Dipolog City.

MA. SANDRA B. PAGENTE

(Affiant)
BFP Dependent ID#SUR-22-007-9
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2022, at

Dipolog City.

Doc No. _____

Page No. _____
Book No. ____
Series of 2022

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, CELIA T. BELLO, of legal age, Filipino, a resident of Estaka, Dipolog CIty,

Zamboanga del Norte after having been duly sworn in accordance with law,
hereby depose and state:

That I am a holder and possessor of a Philippine Passport with Number

P8338877A issued by the Department of Foreign Affairs.
That on March 27, 2022, I found that my said passport was missing;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
passport.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2022, at Dipolog City.

CELIA T. BELLO
(Affiant)
PWD ID#09-7202-000-01537-Dipolog City
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2022, at

Dipolog City.

Doc. No.795

Page No.71

Book No.104

Series of 2022
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ALLENREY P. GUMELO, of legal age, Filipino, married, a resident of Poblacion Bajo, Sergio Osme ña,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am the holder and possessor of SSS identification card(ID) issued by SSS.

That in July 2021, I discovered the said SSS ID was lost;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said SSS ID.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2022, at
Dipolog City.

ALLENREY P. GUMELO
(Affiant)
Philhealth ID#14-025122578-4
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2022, at Dipolog City.

Doc. No.

Page No.

Book No.

Series of 2022
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ANTONIO C. SOLIVA, of legal age, Filipino, married, a resident of Rizal Ave Ext., Estaka, Dipolog City,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am representative of holder and possessor of a Driver’s License with Number A0505003363 and
Official Receipt issued by Land Transportation Office.

That on March 24, 2022, I discovered the said license and official receipt were lost;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said driver’s license and official receipt.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2022, at
Dipolog City.

ANTONIO C. SOLIVA
(Affiant)
Driver’s License#A0505003363
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2022, at Dipolog City.

Doc. No.

Page No.

Book No.

Series of 2022
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, JOCELYN P.LIM, of legal age, Filipino, married, a resident of Poblacion South, Polanco, Zamboanga
del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am representative of holder and possessor of an Official Receipt and Certificate of

Registration(OR/CR) for motor vehicle with Engine No.K6A-7697609;Chassis No.DA63T-588965;CR
No.:334911290; Plate No. 090103 under the name of Noli Lim and OR No.1945231735.

That on March 24, 2022, the original copy of OR/CR of said motor vehicle were lost;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said OR/CR of motor vehicle.
IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2022, at
Dipolog City.

JOCELYN P. LIM
(Affiant)
ID#_______________________
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2022, at Dipolog City.

Doc. No.

Page No.

Book No.

Series of 2022

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, FREDDIE LUGO AVES, of legal age, Filipino, married, a resident of Rizal Ave Ext., Estaka,
Dipolog City, Zamboanga del Norte after having been duly sworn in accordance with law,
hereby depose and state:
That I am the registered owner of a firearm, described as follows:

MAKE KIND CALIBER SERIAL NO.

BINGHAM RIFLE .22 10900678

That my said firearm was put for safekeeping in our house in San Antonio, Polanco,
Zamboanga del Norte;

That personnel from the Philippine National Police came to me and asked me why I did not
renew the license of the said firearm so I went back in San Antonio and look for the said
firearm however it is nowhere to be found now;

That despite effort to recover the same but it was naught.

Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements
and for the purpose of attesting to the loss of the said firearms.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2022,
at Dipolog City.

FREDDIE L. AVES

(Affiant)

Firearm License Card Control No.I-E013599

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2022, at Dipolog City.

Doc. No.__
Page No.__
Book No.__
Series of 2022

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS
I, KIMMY A. PAGADOR, of legal age, Filipino, married, a resident of Upper
Turno, Dipolog City, Zamboanga del Norte after having been duly sworn in
accordance with law, hereby depose and state:

That I am a holder and possessor of the following documents:

1.PRC License 6.Vaccination Card,``````inclusive of my

children’s Keizha Kaye & King

2.Voter’s Identification card 7. LandBank ATM Card

3. GSIS UMID Card 8.BPI ATM Card

4. Philhealth Card 9. TIN Identification Card

5.Pag-ibig MID Card

That on March 21, 2022, my bag containing those important documents

was stolen at the school;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
documents.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2022, at Dipolog City.

KIMMY R. PAGADOR
(Affiant)
Deped ID#1000292-Zamboanga del Norte
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2022, at

Dipolog City.

Doc. No.

Page No.

Book No.

Series of 2022
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, JEFFREY A. TAMALA, of legal age, Filipino, married, a resident of Baybay,

Liloy, Zamboanga del Norte after having been duly sworn in accordance
with law, hereby depose and state:

That I am a holder and possessor of a Philippine Passport issued by the

Department of Foreign Affairs.

That on December 22, 2017, I found that my said passport was missing
after Typhoon Vinta ravaged our place;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
passport.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2022, at Dipolog City.

JEFFREY A. TAMALA
(Affiant)
Driver’s License#N03-07-015720
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2022, at

Dipolog City.

Doc. No.

Page No.

Book No.

Series of 2022
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, LILIBETH G. BUAYA, of legal age, Filipino, single, a resident of Turno, Dipolog City,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose
and state:

That I am a holder/possessor of receipt of pawned jewelry issued by Cebuana Lhuillier

Pawnshop Dipolog Branch with Ticket No.50304sg023370 dated December 26, 2021;

That sometime March 2022, while I was trying to locate the said receipt I could not find it
because it was lost and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements
and for the purpose of attesting to the loss of the said receipt.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2022,
at Dipolog City.

LILIBETH G. BUAYA
(Affiant)
PRC ID#1205785

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2022, at Dipolog City.
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, YULANDA B. MALIGRO, of legal age, Filipino, married, a resident of Anahaw, Galas, Dipolog City,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am the mother of Charies Vir L. Baliton, holder and possessor of her DIPLOMA as graduate of a
course Bachelor of Secondary Education at Saint Vincent’s College Incorporated. That my child left me
the abovesaid documents for safekeeping

That on March 15, 2021, I discovered that folder containing the said documents was lost, and could
not be found. That the lost could be due to fire;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said Diploma and other documents.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2022, at
Dipolog City.

YULANDA B. MALIGRO
(Affiant)
UMID ID#CRN-006-0040-9987-5
 With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2022, at Dipolog City.

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x
 AFFIDAVIT OF LOSS

I, RAMIRA G. GOMEZ, of legal age, Filipino, married, a resident of Dilawa,

Pinan, Zamboanga del Norte, after having been duly sworn in accordance
with law, hereby depose and state:

That I am a holder and possessor of a Passbook issued by Piñan Multi-

purpose Cooperative(Coop) with Account Number 20703968;

That in March 2022, while I was trying to look for the said passbook from my
file where I kept it, I found out that the passbook was lost, and could not be
found;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost;

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

foregoing statements and for the purpose of attesting to the loss of the said
Passbook issued by Coop, and request the replacement of the said
passbook.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

March 2022, at Dipolog City.

RAMIRA G. GOMEZ
(Affiant)
Driver’s License#J01-20-008621
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of March 2022, at

Dipolog City.
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, RONIE M. TURNO,JR, of legal age, Filipino, single, a resident of Disakan, Manukan, Zamboanga del
Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of the original copy of National Certificate(NC) II for Motorcycle
Small Engine Servicing.

That in March 2022 while I was trying to look for the said documents, I found out that the it was lost,
and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said NC II.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2022, at
Dipolog City.

RONIE M. TURNO,JR
(Affiant)
Philhealth ID#14-250130621-4
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2022, at Dipolog City.

Doc. No
Page No
Book No
Series of 2022
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, NENITA N. SISNEROS, of legal age, Filipino, widow, a resident of Turno, Dipolog City, Zamboanga del
Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of Certificate of Registration(CoR) issued by the Bureau of Internal
Revenue for Conching Online Marketing owned by Orlando Jamora Tolin.

That I managed the said business;

That in March 2022 while I was trying to look for the said CoR because we are closing its operation, I
found out that the it was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said Certificate of Registration.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2022, at
Dipolog City.

NENITA N. SISNEROS
(Affiant)
SSS ID#09-1253897-4
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2022, at Dipolog City.

Doc. No
Page No
Book No
Series of 2022
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ALFREDO R. QUIAMJOT,JR, of legal age, Filipino, a resident of Punta, Dipolog City, Zamboanga del
Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of the original copy Motorized Tricycle Operator’s Permit(MTOP)
issued by Local Government of Dipolog City with MTOP DPLG NO. 2021-0241 registered under my
name.

That in March 2022 while I was trying to look for the MTOP of my tricycle, I found out that the it was
lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said MTOP.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2022, at
Dipolog City.

ALFREDO R. QUIAMJOT,JR
(Affiant)
ID#__________________________
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2022, at Dipolog City.

Doc. No
Page No
Book No
Series of 2022
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, EFREN N. ARRO, of legal age, Filipino, married, a resident of Purok 1,

Lugdungan, Dipolog City, Zamboanga del Norte after having been duly sworn in
accordance with law, hereby depose and state:

That I am holder and possessor of a driver’s license issued by Land Transportation

Office(LTO).

That on March 5 2022, I discovered that my wallet containing my said driver’s

license ID was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it
as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
statements and for the purpose of attesting to the loss of the said driver’s license
issued by LTO.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of March
2022, at Dipolog City.

EFREN N. ARRO
(Affiant)
TIN#160-625-984
With photo

SUBSCRIBED AND SWORN to before me this ___ day of March 2022, at Dipolog
City.

DOC.NO.

PAGE NO.

BOOK NO.

SERIES OF 2022
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ANJELYN J. AGECIA, of legal age, Filipino, a resident of Polanco, Zamboanga del

Norte after having been duly sworn in accordance with law, hereby depose and
state:

That I am the attorney-in-fact of holder and possessor of BIR Forms for Capital
Gains Tax and Documentary Stamp Tax issued by BIR for the sale of parcel of land
covered by TCT No.T-74626.

That in March 2022, I discovered that said forms were lost, and could not be
found;

That despite effort to recover the same but it was naught. Hence, I considered it
as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
statements and for the purpose of attesting to the loss of the said BIR Forms.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of March
2022, at Dipolog City.

ANJELYN J. AGECIA
(Affiant)
ID#_________________
With photo

SUBSCRIBED AND SWORN to before me this ___ day of March 2022, at Dipolog
City.

DOC.NO.

PAGE NO.

BOOK NO.
SERIES OF 2022

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, PAUL ALBERT M. LIONG, of legal age, Filipino, single/married, a resident of

DIpolog City, Zamboanga del Norte after having been duly sworn in accordance
with law, hereby depose and state:

That I am holder and possessor of a driver’s license issued by Land Transportation

Office(LTO).

That in March 2022, I discovered that my driver’s license ID was lost, and could
not be found;

That despite effort to recover the same but it was naught. Hence, I considered it
as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
statements and for the purpose of attesting to the loss of the said driver’s license
issued by LTO.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of March
2022, at Dipolog City.

PAUL ALBERT M. LIONG

(Affiant)
TIN#936-099-250
With photo

SUBSCRIBED AND SWORN to before me this ___ day of March 2022, at Dipolog
City.
DOC.NO.

PAGE NO.

BOOK NO.

SERIES OF 2022

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, DELMAR C. BATAC, of legal age, Filipino, married, a resident of Esteban

Barbaso Compound, Galas, Dipolog City, Zamboanga del Norte, after having
been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of a Passbook issued by FICCO- Dipolog

City Branch;

That in March 2022, while I was trying to look for the said passbook from my
file where I kept it, I found out that the passbook was lost, and could not be
found;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost;

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

foregoing statements and for the purpose of attesting to the loss of the said
Passbook issued by FICCO, and request the replacement of the said
passbook.
IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of
March 2022, at Dipolog City.

DELMAR C. BATAC
(Affiant)
TIN#284-745-431
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of March 2022, at

Dipolog City.

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, JOYNER M. ABEJERO, of legal age, Filipino, single, a resident of Dansullan,

Polanco, Zamboanga del Norte after having been duly sworn in accordance with
law, hereby depose and state:
That I am holder and possessor of a driver’s license identification card(ID) issued
by Land Transportation Office(LTO) , Pag-ibig ID, Philhealth ID, Employee ID as
employee of Chowking, Lee Plaza Dipolog City and ATM card issued by Metrobank.

That in February 28, 2022, I discovered that my wallet containing those

identification cards was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it
as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
statements and for the purpose of attesting to the loss of the said driver’s license
issued by LTO, Pag-ibig ID, Philhealth ID, Employee ID and ATM card issued by
Metrobank.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2022, at Dipolog City.

JOYNER M. ABEJERO
(Affiant)
CTC #CCI202020814750
Issued at MTO Polanco,ZN
Issued on March 2, 2022
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2022, at Dipolog
City.

DOC.NO.

PAGE NO.

BOOK NO.

SERIES OF 2022
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, RIO BENJIE J. REPONTE, of legal age, Filipino, single/married, a resident of

Carmen Annex, Ozamiz City after having been duly sworn in accordance with law,
hereby depose and state:

That I am a representative of Endure Medical, Inc.

That I am holder and possessor of a Sales Invoice No. 309869 issued for
Zamboanga del Norte Medical Center, Dipolog City.

That in February 2022, I discovered that the said sales invoice was lost, and could
not be found;

That despite effort to recover the same but it was naught. Hence, I considered it
as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
statements and for the purpose of attesting to the loss of the said sales invoice.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2022, at Dipolog City.

RIO BENJIE J. REPONTE

(Affiant)
SSS ID#08-1558105-7
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2022, at Dipolog
City.

DOC.NO.

PAGE NO.

BOOK NO.

SERIES OF 2022
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, DANILO ANGGOT SAMBULOT, of legal age, Filipino, married, a resident of

Mauswagon, Godod, Zamboanga del Norte after having been duly sworn in
accordance with law, hereby depose and state:

That I am holder and possessor of a driver’s license issued by Land Transportation

Office(LTO) with number J0108000438.

That in February 2022, I discovered that my driver’s license ID was lost, and could
not be found;

That despite effort to recover the same but it was naught. Hence, I considered it
as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
statements and for the purpose of attesting to the loss of the said driver’s license
issued by LTO.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2022, at Dipolog City.

DANILO A. SAMBULOT
(Affiant)
Philhealth ID#23-000979147-2
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2022, at Dipolog
City.

DOC.NO.

PAGE NO.

BOOK NO.

SERIES OF 2022
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ALBERTO B. FALCONETE,JR, of legal age, Filipino, a resident of Labrador, Polanco,Zamboanga

del Nortte, after having been duly sworn in accordance with law, hereby depose and state:

That I am the uncle of VINCE HARVEY G. PATANGAN, who was a Junior Hight School student of
Saint Vincent’s College, Dipolog City;

That he was issued a Form 137 from the said school since he transferred into another school;

That recently, I discovered that his Form 137 was lost after it was required by his new school;

That despite effort to recover the same but it was naught;

Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements
and for the purpose of attesting to the loss of the said document.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2022,
at Dipolog City.

ALBERTO B. FALCONETE,JR.

(Affiant)

Driver’s License#J01-99-030324

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2022, at Dipolog City.

Doc. No.__
Page No.__

Book No.__

Series of 2022

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ROSALINDA A. MANONG, of legal age, Filipino, single, a resident of

Olingan, Dipolog City, Zamboanga del Norte, after having been duly sworn
in accordance with law, hereby depose and state:

That I am the keeper of the Business Plate of MH Real Estate Development,

Corp. which has Business Permit No.001359, situated at Lawag, Galas,
Dipolog City;

That last week, while I was trying to look for the said business plate from
where I kept it, I found out that the business plate was lost, and could not
be found;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost;

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

foregoing statements and for the purpose of attesting to the loss of the said
business plate.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2022, at Dipolog City.

ROSALINDA A. MANONG
(Affiant)
Driver’s License#J01-08-003173
With Photo
SUBSCRIBED AND SWORN to before me this ___ day of _________ 2022, at
Dipolog City.

Doc No. _____

Page No. _____
Book No. ____
Series of 2022

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, VIRGILIA J. PERAS, of legal age, Filipino, single/married, a resident of Turno, Dipolog City,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am the recipient of equipment or accessories of equipment issued by the Zamboanga del Norte Medical Center
as one of its permanent employees, to wit:

ARTICLE Description Date Acquired Cost

AVR 220V/240W,Input- 1/13/2009 P5,000.00

110/220W,Output(Dual
5000W),Gold Source

AVR 220V/240W,Input- 1/13/2009 P5,000.00

110/220W,Output(Dual
5000W),Gold Source

That the said accessories for equipment were under my custody however after the passage of time,
those accessories are missing;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;
As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said AVRs.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2022, at
Dipolog City.

VIRGILIA J. PERAS
(Affiant)
UMID ID#CRN-006-0057-8459-0
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2022, at Dipolog City.

Doc. No
Page No
Book No
Series of 2022

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, HILARIO T. ASUSANO, of legal age, Filipino, single, a resident of

Riverside, Barra, Dipolog City, Zamboanga del Norte , after having been
duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of a document entitled Tonnage

Measurement Certification dated April 14, 2021 issued by Maritime Industry
Authority in Zamboanga City for my ship FB “HILARIO”;
That while I was trying to look for the said Tonnage Measurement
Certification document from where I kept it, I found out that the certificate
was missing, and could not be found;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost;

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

foregoing statements and for the purpose of attesting to the loss of the said
Tonnage Measurement Certification, and request the replacement of the
said document.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2022, at Dipolog City.

HILARIO T. ASUSANO
(Affiant)
Voters ID#7202-0013A-H2266HTA10000-4
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2022, at

Dipolog City.

Doc No. _____

Page No. _____
Book No. ____
Series of 2022

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS
I, JYN P. LAGORRA, of legal age, Filipino, single/married, a resident of
Brgy.Uno, Katipunan, Zamboanga del Norte , after having been duly sworn
in accordance with law, hereby depose and state:

That I am a holder and possessor of a Passbook with Savings Account No.

002-24-0004100 issued by Katipunan Bank;

That I was trying to look for the said Passbook from where I kept it, I found
out that the Passbook was missing, and could not be found;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost;

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

foregoing statements and for the purpose of attesting to the loss of the said
Passbook, and request the replacement of the said passbook.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2022, at Dipolog City.

JYN P. LAGORRA
(Affiant)
Driver’s License#J01-07-004243
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2022, at

Dipolog City.

Doc No. _____

Page No. _____
Book No. ____
Series of 2022
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, GENEFER O. GUINDAL, of legal age, Filipino, married, a resident of Sta.

Isabel, Dipolog City, Zamboanga del Norte after having been duly sworn in
accordance with law, hereby depose and state:

That I am a holder and possessor of a Philippine Passport issued by the

Department of Foreign Affairs.

That on January 24, 2021, I found that my said passport was missing;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
passport.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2022, at Dipolog City.

GENEFER O. GUINDAL
(Affiant)
DSWD 4Ps ID#097202021-7839-00073
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2022, at

Dipolog City.

Doc. No.

Page No.

Book No.

Series of 2022
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ELSA BAROGA LAURIE, of legal age, Filipino, married, a resident of Venus, Sergio Osmena,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of new UMID ID card issued by GSIS, ATM payroll card issued by
Landbank of the Philippines, Pag-ibig identification card and Voter’s Certification.

That on January 27, 20, 2022, my wallet containing those cards was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said UMID ID card issued by GSIS, ATM payroll card issued
by Landbank of the Philippines, Pag-ibig identification card and Voter’s Certification.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2022, at
Dipolog City.

ELSA BAROGA LAURIE

(Affiant)
UMID ID#CRN-006-0048-2839-2
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2022, at Dipolog City.

DOC. NO. _____

PAGE NO._____
BOOK NO.____
SERIES OF 2022
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, RUSTICO GUILLENA, of legal age, Filipino, married to Editha Guillena, resident of Arellano St., Dipolog
City, Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am the registered owner of a parcel of land, more particularly described as follows:

A parcel of land known as Lot 5661, Pls 466, covered by Katibayan ng Orihinal na Titulo Blg.P-35964 situated
at Unidos, Plaridel, Misamis Occidental, containing an area of 5,503 square meters issued by the Register of
Deeds for Misamis Occidental.

That the owner’s copy of the title of the said parcel of land was placed inside the cabinet where I usually keep
my important document but later I was looking for it but it was nowhere to be found;

That despite effort to recover the same but it was naught.

That I considered it as totally lost.

That I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for the purpose
of attesting to the loss of the said owner’s copy of Katibayan ng Orihinal na Titulo Blg.P-35964.

IN WITNESS WHEREOF, I have hereunto affixed my signature this __th day of _______ 2022, at Dipolog
City.

RUSTICO GUILLENA Marital consent:

(Affiant)

Driver’s License#J01-20-010731 EDITHA GUILLENA

SUBSCRIBED AND SWORN to before me this ___th day of ________ 2022, at Dipolog City.

DOC.NO. ______

PAGE NO.___

BOOK NO.___

SERIES OF 2022
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

WE, RENAN L. APIAG, of legal age, and MAVIL C. APIAG, minor, Filipino, a
resident of Minaog, Dipolog City, Zamboanga del Norte after having been
duly sworn in accordance with law, hereby depose and state:

That I, Renan L. Apiag, am the father of Mavil C. Apiag, a minor;

That my child Mavil C. Apiag is a holder and possessor of ATM card issued
by LandBank of the Philippines which was used for benefits of 4Ps of DSWD;

That on January 20, 2022, my child discovered that the said ATM card was
lost;

That despite effort to recover the same but it was naught. Hence, we
considered it as totally lost.

As such, we are executing this Affidavit of Loss to attest to the truth of the
foregoing statements and for the purpose of attesting to the loss of the said
ATM card.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2021, at Dipolog City.

RENAN L. APIAG
(Affiant)
Voters ID#72020129AH1181RLA10000-5
With photo

MAVIL C.APIAG
(Affiant)
DSWD 4Ps ID#097202007-7851-00001
SUBSCRIBED AND SWORN to before me this ___ day of _________ 2022, at
Dipolog City.

Doc. No.

Page No.

Book No.

Series of 2022

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, JONATHAN T. LACANG, of legal age, Filipino, married, a resident of Sicayab, Dipolog City,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of the original copy Motorized Tricycle Operator’s Permit(MTOP)
issued by Local Government of Dipolog City with MTOP DPLG NO. 2021-0063 registered under my
name.

That in December 2021 while I was trying to look for the MTOP of my tricycle, I found out that the it
was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said MTOP.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2022, at
Dipolog City.

JONATHAN L. LAGANG
 (Affiant)
PNP ID#21J1100304
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2022, at Dipolog City.

Doc. No
Page No
Book No
Series of 2022

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x
 AFFIDAVIT OF LOSS

I, JAY ALBERT DAGAYLOAN RUBI, of legal age, Filipino, married, a resident

of Barangay Guinles, Polanco, Zamboanga del Norte, after having been duly
sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of a Policy Contract, issued by Armed

Forces and Police Mutual Benefits Association, Inc.(AFPMBAI);

That in December 2021, while I was trying to look for the said Policy
Contract from my file where I kept it, I found out that the certification was
lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost;

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

foregoing statements and for the purpose of attesting to the loss of the said
Policy Contract issued by AFPMBAI.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2022, at Dipolog City.

JAY ALBERT DAGAYLOAN RUBI

(Affiant)
PNP ID No.20J2100014
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2022, at

Dipolog City.

DOC. NO.

PAGE NO.

BOOK NO.

SERIES OF 2022
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ASTROME B. CIMAFRANCA, of legal age, Filipino, married, a resident of Isis,

Polanco, Zamboanga del Norte after having been duly sworn in accordance with
law, hereby depose and state:

That I am holder and possessor of a driver’s license issued by Land Transportation

Office(LTO) and OSCA ID issued by Office of Senior Citizen’s Affairs(OSCA).

That in January 2022, I discovered that my wallet containing driver’s license ID

and OSCA ID was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it
as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
statements and for the purpose of attesting to the loss of the said driver’s license
issued by LTO and OSCA ID.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2022, at Dipolog City.

ASTROME B. CIMAFRANCA
(Affiant)
ID#______________________
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2022, at Dipolog
City.

DOC.NO.

PAGE NO.

BOOK NO.

SERIES OF 2022
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, TEOFILA R. MAURICIO, of legal age, Filipino, widow, a resident of Sitog, Katipunan, Zamboanga del
Norte after having been duly sworn in accordance with law, hereby depose and state:

That my late spouse Rogelio F. Mauricio is a holder and possessor of an identification card as retired
member of the Armed Forces of the Philippines with number 597347 PA;

That recently, I discovered that an identification card which I usually put in my file folder of
documents was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said identification card.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2022, at
Dipolog City.

TEOFILA R. MAURICIO
(Affiant)
AFP Dependent ID#D94-1546
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2022, at Dipolog City.

DOC.NO.

PAGE NO.

BOOK NO.

SERIES OF 2022
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, HAZEL L. LACTUAN, of legal age, Filipino, married, a resident of Gulayon, Dipolog City, Zamboanga
del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of a sticker for the Motorized Tricycle Operator’s Permit(MTOP)
issued by Local Government of Dipolog City with MTOP DPLG NO. 2021-0158 registered under my
name.

That on November 19, 2021, while I was trying to look for the sticker glued on the front window of
the tricycle, I found out that the sticker was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said sticker.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2022, at
Dipolog City.

HAZEL L. LACTUAN
(Affiant)
SSS ID#33-7110645-2
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2022, at Dipolog City.
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, RAYMOND C. TEJADA, of legal age, Filipino, single, a resident of Sta.Filomena,Dipolog City,

Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am holder and possessor of a driver’s license issued by Land Transportation Office(LTO).

That on December 24, 2021, I discovered that driver’s license was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said driver’s license issued by LTO.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2022, at
Dipolog City.

RAYMOND C. TEJADA
(Affiant)
UMID ID#CRN-0111-0083111-0
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2022, at Dipolog City.

DOC.NO.

PAGE NO.

BOOK NO.
SERIES OF 2022

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ADRIAN B. AGAC-AC, of legal age, Filipino, married, a resident of Purok

Caimito, Tuburan, Pagadian City, Zamboanga del Sur, after having been
duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of the Counter Receipt Number 118731

with amount of 164, 754.04 issued by DCTGMI-Sindangan, Zamboanga del
Norte Branch to IPI for goods delivered;

That I am an employee of IPI;

That recently, while I tried to look for the said Counter Receipt on the goods
delivered to them, I found out that it was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost;

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

foregoing statements and for the purpose of attesting to the loss of the said
counter receipt.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2022, at Dipolog City.

ADRIAN B. AGAC-AC
 (Affiant)
Driver’s License#J03-17-002086
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2022, at

Dipolog City.

Doc No. _____

Page No. _____
Book No. ____
Series of 2022

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, EUSEBIO M. FALCONETE, of legal age, Filipino, married, a resident of Biasong, Dipolog City,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of a sticker for the Motorized Tricycle Operator’s Permit(MTOP)
issued by Local Government of Dipolog City with MTOP DPLG NO. 2021-1919 registered under my
name.

That on December 28, 2021, while I was trying to look for the sticker glued on the front window of the
tricycle, I found out that the sticker was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said sticker.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2021, at
Dipolog City.

EUSEBIO M. FALCONETE
(Affiant)
Driver’s License#J01-70-001300
With Photo
SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at Dipolog City.

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, CJ ABAD LAULONG of legal age, Filipino, single, a resident of Gulayon, Dipolog City, Zamboanga del
Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of a slip of BIR Claim Slip#0159 issued on August 11, 2021 issued by
Bureau of Internal Revenue for eCAR of taxes paid on sale of parcel of land covered by OCT No.P-995.

That on the same date, while I was trying to look for my said claim slip from my file folder, then I
found out that my claim slip was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said claim slip and reissuance of the same and claiming the
documents at the Bureau of Internal Revenue anent to the slip.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2021, at
Dipolog City.

CJ ABAD LAULONG
 (Affiant)
Voters ID#72020167BD3099CAL20000-2
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at Dipolog City.

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, AIDA E. TUDIO, of legal age, Filipino, married, a resident of Bolicon, Turno,

Dipolog City, Zamboanga del Norte after having been duly sworn in
accordance with law, hereby depose and state:

That I am a holder and possessor of ATM card issued by LandBank of the

Philippines which was used for benefits of 4Ps of DSWD;

That on December 13, 2021, I discovered that the said ATM card was lost;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
ATM card.
IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of
__________ 2021, at Dipolog City.

AIDA E. TUDIO
(Affiant)
OSCA ID Control No.15823-Dipolog City
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at

Dipolog City.

Doc. No.

Page No.

Book No.

Series of 2021

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ELISEO A. VAILOCES, of legal age, Filipino, a resident of Minaog, Dipolog

City, Zamboanga del Norte after having been duly sworn in accordance
with law, hereby depose and state:

That I am a holder and possessor of a Office of the Senior Citizen’s

Affairs(OSCA) Identification Card with Control No. 10741 and ATM card
issued by Landbank;

That I discovered that the said OSCA ID card and ATM card were lost;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.
As such, I am executing this Affidavit of Loss to attest to the truth of the
foregoing statements and for the purpose of attesting to the loss of the said
OSCA ID card and ATM card.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2021, at Dipolog City.

ELISEO A. VAILOCES
(Affiant)
OSCA ID#10741-Dipolog City
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at

Dipolog City.

Doc. No.

Page No.

Book No.

Series of 2021

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ROEL A. SUMAYLO, of legal age, Filipino, married, a resident of San

Nicolas, Dapitan City, Zamboanga del Norte after having been duly sworn
in accordance with law, hereby depose and state:

That I am a holder and possessor of ATM card issued by Development Bank

of the Philippines which was used as my payroll ATM card from my employer
Department of Public Works and Highways;

That it was due for replacement for a new card;

That on December 17, 2021, I discovered that the said ATM card was lost;
That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
ATM card.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2021, at Dipolog City.

ROEL A. SUMAYLO
(Affiant)
Voter’s ID#7201-0142A-D2571RAS10003-1
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at

Dipolog City.

Doc. No.

Page No.

Book No.

Series of 2021

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, R, of legal age, Filipino, single, a resident of Upper Pianon, Kalawit, Zamboanga del Norte after
having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of a Smart Sim card with number 09397577583;

That the Smart Simcard was used for my business of retailing load;

That in December 2021, I discovered that my said simcard was lost, and could not be found;
That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said sim card and thereafter requesting replacement of the
same.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2021, at
Dipolog City.

RELYN DOPOL BORJA

(Affiant)
Philhealth ID#12-050888510-0
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at Dipolog City.

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x
 AFFIDAVIT OF LOSS

I, JOBANIE R. MONTILLA, of legal age, Filipino, married, a resident of 438

Bliss, Sta. Isabel, Dipolog City, Zamboanga del Norte after having been duly
sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of a Philippine Passport issued by the

Department of Foreign Affairs.

That sometime in December 2017 during Typhoon Vinta, my said passport

was missing;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
passport.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2021, at Dipolog City.

JOBANIE R. MONTILLA
(Affiant)
PRC ID#0429033
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at

Dipolog City.

Doc. No.

Page No.

Book No.

Series of 2021

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS
I, DINDO C. DALMAN, of legal age, Filipino, married, a resident of Isis,
Polanco, Zamboanga del Norte after having been duly sworn in accordance
with law, hereby depose and state:

That principal Lorena Asilo Baquial is holder and possessor of official receipt
with OR No.1430395 issued by Supreme Court for bail bond.

That principal has lost it;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
original copy of the official receipt.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2021, at Dipolog City.

DINDO C. DALMAN
(Affiant)
Driver’s License#J01-01-035822
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at

Dipolog City.

Doc. No.

Page No.

Book No.

Series of 2021

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS
I, CARLYN R. MONTILLA, of legal age, Filipino, married, a resident of 438
Bliss, Sta. Isabel, Dipolog City, Zamboanga del Norte after having been duly
sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of a Philippine Passport issued by the

Department of Foreign Affairs.

That sometime in December 2017 during Typhoon Vinta, my said passport

was missing;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
passport.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2021, at Dipolog City.

CARLYN R. MONTILLA
(Affiant)
Pag-ibig MID No. 1212-0522-5171
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at

Dipolog City.

Doc. No.

Page No.

Book No.

Series of 2021

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS
I, TERESITA B. DUTERTE, of legal age, Filipino, married, a resident of
Poblacion South, Polanco, Zamboanga del Norte , after having been duly
sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of a Passbook with Account No.

001220016641 issued by Katipunan Bank-Dipolog City;

That in October 2021, while I was trying to look for the said Passbook from
where I kept it, I found out that the Passbook was lost, and could not be
found;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost;

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

foregoing statements and for the purpose of attesting to the loss of the said
Passbook, and request the replacement of the said passbook.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2021, at Dipolog City.

TERESITA B. DUTERTE
(Affiant)
UMID ID#CRN-0111-2933429-0
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at

Dipolog City.

Doc No. _____

Page No. _____
Book No. ____
Series of 2021
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ADRIAN B. AGAC-AC, of legal age, Filipino, married, a resident of Purok

Caimito, Tuburan, Pagadian City, Zamboanga del Sur after having been
duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of ATM card issued by Metrobank which

was used a depository account of my expenses refund as an employee of
IPI;

That on December 3, 2021, I discovered that the said ATM card was lost;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
ATM card.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2021, at Dipolog City.

ADRIAN B. AGAC-AC
(Affiant)
Drivers License#J03-17-002086
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at

Dipolog City.

Doc. No.

Page No.

Book No.

Series of 2021
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ELLEN ABA-A OLARION, of legal age, Filipino, married, a resident of Poblacion South,
Polanco,Zamboanga del Nortte, after having been duly sworn in accordance with law, hereby
depose and state:

That I am a graduate of a course:Bachelor of Secondary Education at Saint Vincent’s College,

Dipolog City in year 1992;

That I was issued a Diploma after my graduation;

That recently, I discovered that the original copy of my diploma was lost;

That despite effort to recover the same but it was naught;

Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements
and for the purpose of attesting to the loss of the said document.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2021,
at Dipolog City.

ELLEN A. OLARIO

(Affiant)

TIN#905-858-774

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at Dipolog City.

Doc. No.__

Page No.__

Book No.__
Series of 2021

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, LESLIE M. TARAN, of legal age, Filipino, widow, a resident of Gulayon,Dipolog

City, Zamboanga del Norte after having been duly sworn in accordance with law,
hereby depose and state:

That I am holder and possessor of a check and loan voucher issued by Social
Security System sometime in March 2020.

That sometime December 2020, I discovered that said check and voucher were
lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it
as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
statements and for the purpose of attesting to the loss of the said check and
voucher.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2021, at Dipolog City.

LESLIE M. TARAN
(Affiant)
UMID ID#CRN-0006-2600405-3
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at Dipolog
City.

DOC.NO.

PAGE NO.

BOOK NO.

SERIES OF 2021
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, DIANABETH OLILA ANGCAP, of legal age, Filipino, single, a resident of Purok De

Oro Highway, Olingan,Dipolog City, Zamboanga del Norte after having been duly
sworn in accordance with law, hereby depose and state:

That I am holder and possessor of a driver’s license issued by Land Transportation

Office(LTO).

That on November 24, 2021, I discovered that driver’s license was lost, and could
not be found;

That despite effort to recover the same but it was naught. Hence, I considered it
as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
statements and for the purpose of attesting to the loss of the said driver’s license
issued by LTO.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2021, at Dipolog City.

DIANABETH OLILA ANGCAP

(Affiant)
Passport ID#P2779139B
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at Dipolog
City.

DOC.NO.

PAGE NO.

BOOK NO.
SERIES OF 2021

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ROSETTE LYN M. PIZARRAS, of legal age, Filipino, single, a resident of

Sianib, Polanco, Zamboanga del Norte after having been duly sworn in
accordance with law, hereby depose and state:

That I am a holder and possessor of a Philippine Passport issued by the

Department of Foreign Affairs.

That on September 27 2021, I found that my said passport was missing;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
passport.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2021, at Dipolog City.

ROSETTE LYN M. PIZARRAS

(Affiant)
Driver’s License#J07-18-002253
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at

Dipolog City.
Doc. No.

Page No.

Book No.

Series of 2021

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, JONATHAN U. GUTANG, guardian of ROBINSON U. GUTANG, of legal age,

Filipino, single, a resident of Estaka, Dipolog City, Zamboanga del Norte
after having been duly sworn in accordance with law, hereby depose and
state:

That I am a holder and possessor of ATM card for 4Ps under the name of
Trinidad A. Ugnay with Robinson U. Gutang as beneficiary and it was issued
by Landbank of the Philippines;

That on November 29, 2021, I discovered that the said ATM card was lost;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
ATM card.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2021, at Dipolog City.

JONATHAN U. GUTANG
 (Affiant)
Drivers License#J01-17-004765
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at

Dipolog City.

Doc. No.

Page No.

Book No.

Series of 2021

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, PATERNA D. SANGUAL, of legal age, Filipino, single/married, a resident of

Betlehem, Polanco, Zamboanga del Norte, after having been duly sworn in
accordance with law, hereby depose and state:
That I am a holder and possessor of a Passbook with Account No.
10A022136 issued by Rural Bank of Rizal-Polanco, Zamboanga del Norte
Branch for Betlehem Women’s Association;

That in November 2021, while I was trying to look for the said Passbook
from where I kept it, I found out that the Passbook was lost, and could not
be found;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost;

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

foregoing statements and for the purpose of attesting to the loss of the said
Passbook, and request the replacement of the said passbook.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2021, at Dipolog City.

PATERNA D. SANGUAL
(Affiant)
ID#_____________________
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at

Dipolog City.

Doc No. _____

Page No. _____
Book No. ____
Series of 2021
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, MA. ANTONETTE D11. GONZALES , of legal age, Filipino, single, a resident of 609 Rizal Ave.,
Central Barangay, Dipolog City , after having been duly sworn in accordance with law, hereby
depose and state:

That I am a graduate of a course:Bachelor of Science in Commerce-Major in Accounting at

Saint Vincent’s College, Dipolog City in March 1991;

That I was issued a Diploma after my graduation;

That recently, I discovered that the original copy of my diploma was lost;

That despite effort to recover the same but it was naught;

Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements
and for the purpose of attesting to the loss of the said document.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2021,
at Dipolog City.

MA. ANTONETTE D. GONZALES

(Affiant)

DepEd Employee ID#1700064

Schools Division of Zamboanga del Norte

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at Dipolog City.

Doc. No.__

Page No.__

Book No.__

Series of 2021
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, MA.ZEARA C. CASTOLO, of legal age, Filipino, single, a resident of 111

Martinez St., Sta.Cruz, Dipolog City, Zamboanga del Norte after having
been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of Automated Teller Machine(ATM) card

with Savings Account No.3806 6311 90 issued by Landbank of the
Philippines ;.

That on November 19, 2021, I discovered that my said ATM card was lost
and I did not know how it was lost;

That its whereabouts cannot anymore be ascertained despite due and

diligent search made and undertaken;

That I now desire and hereby request Landbank to issued a new ATM card in
lieu of the one lost; that I am willing to surrender the lost ATM card in the
event that same could be found and located; that I bind myself to hold
Landbank free and harmless from any loss or damage that may arise or it
incur in connection with the issuance of a new ATM card;

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

foregoing statements and for the purpose of attesting to the loss of the said
ATM card.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2021, at Dipolog City.

MA. ZEARA C. CASTOLO

(Affiant)
Andres Bonifacio College School ID#HSD130001
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at

Dipolog City.
Doc. No.

Page No.

Book No.

Series of 2021

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, RUEL ABITONA CASIPONG, of legal age, Filipino, single, a resident of San Francisco, Liloy,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of claim slip for my UMID ID issued by GSIS through Landbank of the
Philippines

That I was trying to look for my said claim slip, then I found out that it was lost, and could not be
found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said claim slip.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2021, at
Dipolog City.

RUEL ABITONA CASIPONG

(Affiant)
PRC ID#0015988-Agriculturist
With Photo
SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at Dipolog City.

DOC. NO. _____

PAGE NO._____
BOOK NO.____
SERIES OF 2021

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, MARY SAINT NONO CENAS, of legal age, Filipino, single, a resident of Padre Ramon Ext., Estaka,
Dipolog City, Zamboanga del Norte after having been duly sworn in accordance with law, hereby
depose and state:

That I am a holder and possessor of Person with Disabilities(PWD) identification card(ID);

That on October 30, 2021, while I was trying to look for my said PWD ID from my pocket, then I found
out that the ID was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said PWD ID.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2021, at
Dipolog City.

MARY SAINT NONO CENAS

 (Affiant)
Voters ID#7202-0056A-E0387MNC20000
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at Dipolog City.

DOC. NO. _____

PAGE NO._____
BOOK NO.____
SERIES OF 2021

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, AJILYN L. DURON, of legal age, Filipino, married, a resident of Dawo, Dapitan City, Zamboanga del
Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of an original tickets for Cebu Pacific Airlines with booking reference
number RH7VVG for the following passengers: AJILYN L. DURON, GLORIA LACHAMA, and ANGEL
SHEDORI DURON.

That last week, while I was trying to look for my said original tickets from my file folder, then I found
out that the tickets were lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said original tickets.
IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2021, at
Dipolog City.

AJILYN L. DURON
(Affiant)
PRC ID#1648107-Professional Teacher
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at Dipolog City.

DOC. NO. _____

PAGE NO._____
BOOK NO.____
SERIES OF 2021

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, DARIO M. MANDANTES, of legal age, Filipino, married, a resident of Isis, Polanco, Zamboanga del
Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of an original copy of e-Certificate Authorizing Registration(eCAR)

issued issued by Bureau of Internal Revenue with No. eCR201900532874.

That last week, while I was trying to look for my said eCAR from my file folder, then I found out that
the eCARs were lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;
As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said eCAR and reissuance of the same and claiming the
documents at the Bureau of Internal Revenue anent to the slip.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2021, at
Dipolog City.

DARIO M. MANDANTES
(Affiant)
Atty Roll No.51575
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at Dipolog City.

DOC. NO. _____

PAGE NO._____
BOOK NO.____
SERIES OF 2021

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, JOSEFE CABO SALAZAR, of legal age, Filipino, married, a resident of Purok

4, Lapu lapu,Pinan, Zamboanga del Norte after having been duly sworn in
accordance with law, hereby depose and state:

That I am a holder and possessor of payroll ATM card issued by Eastwest

Bank and Driver’s License card issued by LTO;.
That in the first week of November 2021, I discovered that my wallet
containing the said ATM card and Drivers License card was lost;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
payroll ATM card and Drivers License card.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2021, at Dipolog City.

JOSEFE CABO SALAZAR

(Affiant)
UMID ID#CRN-0111-232394104
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at

Dipolog City.

Doc. No.

Page No.

Book No.

Series of 2021

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, MARIO LOZANO MIGUEL, of legal age, Filipino, married, a resident of Matam, Katipunan,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:
That I am a holder and possessor of a cellular phone with Smart Sim card with number 09685213726;

That the Smart Simcard was issued to me by Department of Education and used for work-related
purposes;

That on October 23, 2021, I discovered that my said cellular phone with simcard inside was lost, and
could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said cellular phone with sim card and thereafter requesting
replacement of the same.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2021, at
Dipolog City.

MARIO LOZANO MIGUEL

(Affiant)
PRC ID#1004772 valid until 01/19/2022
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at Dipolog City.

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS
I, GERBIE E. AVES, of legal age, Filipino,widow, a resident of Isis, Polanco,
Zamboanga del Norte after having been duly sworn in accordance with law,
hereby depose and state:

That I am holder and possessor of a Charge Invoice issued by Akao Farms

with number 84872 dated September 29, 2021 with the amount of
P1,800.00;

That on November 2, 2021, I discovered that the said Charge Invoice was
lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost;

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

foregoing statements and for the purpose of attesting to the loss of the said
Charge Invoice.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2021, at Dipolog City.

GERBIE E. AVES
(Affiant)
Driver’s License#J01-18-002616

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at

Dipolog City.

DOC.NO.

PAGE NO.

BOOK NO.

SERIES OF 2021
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, DAVY RICHO AQUE, of legal age, Filipino, married, a resident of Ramos

Village, Sta.Filomena, Dipolog City, Zamboanga del Norte after having been
duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of a TOP issued by LTO-Davao City for my

motor vehicle with Plate KAB 1314;.

That sometime June 2021, I discovered that my wallet containing the said
TOP was lost;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
TOP.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2021, at Dipolog City.

DAVY RICHO AQUE

(Affiant)
DL#L02-00-140982
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at

Dipolog City.

Doc. No.

Page No.

Book No.

Series of 2021
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, PELIGRENA B. CAMATURA, of legal age, Filipino, married, a resident of

Olingan, Dipolog City, Zamboanga del Norte after having been duly sworn
in accordance with law, hereby depose and state:

That I am a holder and possessor of a Senior Citizen’s ID issued by Office of

the Senior Citizen’s Affairs.

That sometime last week, I discovered that my wallet containing the said
identification card was lost;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
Senior Citizen’s ID issued by OSCA.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2021, at Dipolog City.

PELIGRENA B. CAMATURA
(Affiant)
ID#___________________
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at

Dipolog City.

Doc. No.

Page No.

Book No.

Series of 2021
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, HAIDE B. DALIGDIG, of legal age, Filipino, single, resident of Sta.Filomena, Dipolog City, Zamboanga del
Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am the registered co-owner of a parcel of land, more particularly described as follows:

A parcel of land known as Lot No.2496-A, PSD-09-079838, covered by Transfer Certificate of Title No.127-
2018000791 situated at Imelda, Labason, Zamboanga del Norte, containing an area of 576 square meters issued
by the Register of Deeds for Zamboanga del Norte.

That the owner’s copy of the title of the said parcel of land was placed inside a brown envelope but it was lost
after I left it in a passenger tricycle;

That despite effort to recover the same but it was naught.

That I considered it as totally lost.

That I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for the purpose
of attesting to the loss of the said owner’s copy of Transfer Certificate of Title No.127-2018000791.

IN WITNESS WHEREOF, I have hereunto affixed my signature this __th day of _______ 2021, at Dipolog
City.

HAIDE B. DALIGDIG

(Affiant)

Driver’s License#J01-20-010731
SUBSCRIBED AND SWORN to before me this ___th day of ________ 2021, at Dipolog City.

DOC.NO. ______

PAGE NO.___

BOOK NO.___

SERIES OF 2021

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, JEVEY GABUCAN BUSTALIÑO, of legal age, Filipino, married, resident of Purok San Roque, Catalina
Daymiel Drive, Sicayab, Dipolog City, Zamboanga del Norte after having been duly sworn in accordance with
law, hereby depose and state:

That I am the registered owner of a parcel of land, more particularly described as follows:

A parcel of land known as Lot No.4137-C-8, PSD-09-039821, covered by Transfer Certificate of Title No.T-
67588 situated at Guinles, Polanco, Zamboanga del Norte issued by the Register of Deeds for Zamboanga del
NOrte.

That the owner’s copy of the title of the said parcel of land was placed inside a brown envelope but it was
misplaced;

That despite effort to recover the same but it was naught.

That I considered it as totally lost.

That I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for the purpose
of attesting to the loss of the said owner’s copy of Transfer Certificate of Title No.T-67588.

IN WITNESS WHEREOF, I have hereunto affixed my signature this __th day of _______ 2021, at Dipolog
City.

JEVEY GABUCAN BUSTALIÑO

(Affiant)

Driver’s License#J01-14-002161
SUBSCRIBED AND SWORN to before me this ___th day of ________ 2021, at Dipolog City.

DOC.NO. ______

PAGE NO.___

BOOK NO.___

SERIES OF 2021

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, PETER JOHN CABALIDA NATAA, of legal age, Filipino, single, a resident of Sta. Isabel, Dipolog City,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of a cellular phone inclusive of Globe Sim card with number
09950803234.

That on October 21, 2021, I discovered that my said cellular phone with simcard inside was lost, and
could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said cellular phone with sim card and thereafter requesting
replacement of the same.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2021, at
Dipolog City.

PETER JOHN C. NATAA

(Affiant)
Drivers License#J01-14-003231
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at Dipolog City.
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ROSEMARIE N. CASTILLON, of legal age, Filipino, single, a resident of Purok

Utanon, Lingasad, Polanco, Zamboanga del Norte after having been duly
sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of a Philippine Passport issued by the

Department of Foreign Affairs.

That sometime in the first week of October 2021, I found that my said
passport was missing due to flood in our house;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
passport.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2021, at Dipolog City.

ROSEMARIE N. CASTILLON
(Affiant)
ID#________________________
With photo
SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at
Dipolog City.

Doc. No.

Page No.

Book No.

Series of 2021

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, GENESIS T. PARAS, of legal age, Filipino, single/married, a resident of VCH, Obay, Polanco
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose
and state:

That I am a holder/possessor of receipt for pawned jewelries issued by RD Pawnshop with

Serial No. 25325254 dated October 21, 2021;

That on the same date, while I was trying to locate the said receipt I could not find it because it
was lost and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements
and for the purpose of attesting to the loss of the said receipt.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ____ day of __________
2021, at Dipolog City.

GENESIS T. PARAS
(Affiant)
 Driver’s License#J01-15-003354
With photo,

SUBSCRIBED AND SWORN to before me this ___ day of ________ 2021, at Dipolog City.

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, RONALD J. BUSTALINO, of legal age, Filipino, married, a resident of

Guinles, Polanco, Zamboanga del Norte after having been duly sworn in
accordance with law, hereby depose and state:

That I am a holder and possessor of a Philippine Passport issued by the

Department of Foreign Affairs which I was about to renew and I already
applied an online reservation of schedule.

That the said reservation was already printed which scheduled November 3,
2021, 8 in the morning at DFA Clarin, Misamis Occindental;

That on the other day, I found that my said online reservation slip was lost
and the email account I used was forgotten;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
online reservation slip for online renewal of passport.
IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of
__________ 2021, at Dipolog City.

RONALD J. BUSTALINO
(Affiant)
Passport#P1969988A
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at

Dipolog City.

Doc. No.

Page No.

Book No.

Series of 2021

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, GERBIE E. AVES, of legal age, Filipino,widow, a resident of Isis, Polanco,

Zamboanga del Norte after having been duly sworn in accordance with law,
hereby depose and state:

That I am holder and possessor of a Charge Invoice issued by Akao Farms

with number 72352 dated February 8, 2021 with the amount of P20,400.00;

That on October 19, 2021, I discovered that the said Charge Invoice was
lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost;

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

foregoing statements and for the purpose of attesting to the loss of the said
Charge Invoice.
IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of
__________ 2021, at Dipolog City.

GERBIE E. AVES
(Affiant)
Driver’s License#J01-18-002616

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at

Dipolog City.

DOC.NO.

PAGE NO.

BOOK NO.

SERIES OF 2021

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, LLOYD R. PASCUAL, of legal age, Filipino, single/married, a resident of Dapitan City, Zamboanga del
Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a liaison officer of Gud Moto Trading Inc. and holder and possessor of Official Receipts on
the renewal of registration of the two motor vehicles with Plate No.NC42935, Motor No.2HD-011315,
CR No.201197813 and with Plate No.090810, Motor No.AE54-486030, CR No.39490343-4

That on September 20, 2021, I discovered that folder containing the Original Copies of Official
Receipts of the said vehicles were lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said Official Receipts9.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2021, at
Dipolog City.
 LLOYD R. PASCUAL
(Affiant)
Driver’s License#J01-05-002100

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at Dipolog City.
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, SEBENIANA S. GUMANOD, of legal age, Filipino, single, a resident of Serongan, Manukan,

Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of my Automated Teller Machine(ATM) cash card issued by
Landbank-Dipolog City for my DSWD 4Ps.

That on September 28, 2021, I found out my said ATM card was lost;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said ATM card issued by Landbank.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2021, at
Dipolog City.

SEBENIANA S. GUMANOD
 (Affiant)
DSWD 4Ps ID#097207014-0146-00189
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at Dipolog City.

Doc. No.

Page No.

Book No.

Series of 2021

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, PETER JOHN CABALIDA NATAA, of legal age, Filipino,single, a resident of

Sta. Isabel, Dipolog City, Zamboanga del Norte after having been duly sworn
in accordance with law, hereby depose and state:

That I am holder and possessor of an official receipt issued by Toyota

Cagayan de Oro, Inc with number 5000000000070119 for the safeguard tax
of motor vehicle in the amount of P78,400.00;

That on October 13, 2021, I discovered that the official receipt was lost,
and could not be found;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost;

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

foregoing statements and for the purpose of attesting to the loss of the said
official receipt.
IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of
__________ 2021, at Dipolog City.

PETER JOHN CABALIDA NATAA

(Affiant)
Driver’s License#J01-14-003231

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at

Dipolog City.

DOC.NO.

PAGE NO.

BOOK NO.

SERIES OF 2021

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, REBECCA R. BERLAN, of legal age, Filipino, married, a resident of Lingasad, Polanco, Zamboanga del
Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of Plate Number issued by Land Transportation Office for a Isuzu
DMAX 4x2 motor vehicle with Plate Number NXO714 registered under my name;

That on October 2, 2021, I discovered that the said Plate number was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said Plate number and thereafter requesting replacement
of the same.
IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2021, at
Dipolog City.

REBECCA R. BERLAN
(Affiant)
OSCA ID#2961-Dipolog City
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at Dipolog City.

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ROE OMAR M. ICAO , of legal age, Filipino, married, a resident of Piñan, Zamboanga del
Norte, after having been duly sworn in accordance with law, hereby depose and state:

That I am a graduate of Bachelor of Science in Accountancy at Andres Bonifacio College,

Dipolog City;

That I was issued a Diploma after my graduation;

That recently, I discover that the original copy of my diploma is lost;

That despite effort to recover the same but it was naught;

Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements
and for the purpose of attesting to the loss of the said document.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2021,
at Dipolog City.

ROE OMAR M. ICAO

(Affiant)

PRC#132886

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at Dipolog City.

Doc. No.__

Page No.__

Book No.__

Series of 2021

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS
I, JENEBEB G. ANTINIRO, of legal age, Filipino, married, a resident of Purok
Morning Star, Olingan, Dipolog City, after having been duly sworn in
accordance with law, hereby depose and state:

That I am a holder and possessor of a Passbook issued by Katipunan Bank-

Dipolog City Branch under my name;

That in June 2021, while I was trying to look for the said Passbook from
where I kept it, I found out that the Passbook was lost, and could not be
found;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost;

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

foregoing statements and for the purpose of attesting to the loss of the said
Passbook, and request the replacement of the said passbook.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2021, at Dipolog City.

JENEBEB G. ANTINIRO
(Affiant)
Driver’s License#J01-14-002551
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at

Dipolog City.

Doc No. _____

Page No. _____
Book No. ____
Series of 2021
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ELIZABETH G. MAGSAYO, of legal age, Filipino, widow, a resident of

Minlasag, Sibutad, Zamboanga del Norte, after having been duly sworn in
accordance with law, hereby depose and state:

That I am a holder and possessor of an AFPSLAI Red wPassbook issued by

AFPSLAI;

That last week, while I was trying to look for the said AFPSLAI Passbook from
where I kept it, I found out that the AFPSLAI Passbook was lost, and could
not be found;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost;

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

foregoing statements and for the purpose of attesting to the loss of the said
AFPSLAI Passbook, and request the replacement of the said passbook.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2021, at Dipolog City.

ELIZABETH G. MAGSAYO
(Affiant)
PRC ID#0042714-Midwife
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at

Dipolog City.

Doc No. _____

Page No. _____
Book No. ____
Series of 2021
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, DIONISIO A. DALIDA, of legal age, Filipino, married, resident of Milad, Polanco, Zamboanga del Norte
after having been duly sworn in accordance with law, hereby depose and state:

That I am one of the heirs of late Spouses Juanito Dalida and Pilar Adriatico, owners of the following parcels of
land, to wit:

1. A parcel of land known as Lot 4, CCS-09-08-000048, covered by Original Certificate of Title No. P-
27641 located at Milad, Polanco, Zamboanga del Norte, containing an area of 48,184 square meters.

2. A parcel of land known as Lot 5, CCS-09-08-000048, covered by Original Certificate of Title No. P-
27638 located at Milad, Polanco, Zamboanga del Norte, containing an area of 49,998 square meters.

3. A parcel of land known as Lot 1, CCS-09-08-000048, covered by Original Certificate of Title No. P-
27639 located at Milad, Polanco, Zamboanga del Norte, containing an area of 49,998 square meters.

That since the death of my parents, I together with my siblings tried to find the owner’s copies of the title of
abovementioned parcels of land and could not locate it anymore;

That despite effort to recover the same but it was naught.

That I considered it as totally lost.

That I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for the purpose
of attesting to the loss of the said owner’s copies of the certificates of title.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2021, at Dipolog
City.

DIONISIO A. DALIDA

(Affiant)

ID#______________________

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at Dipolog City.
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, DIONISIO A. DALIDA, of legal age, Filipino, married, resident of Milad, Polanco, Zamboanga del Norte
after having been duly sworn in accordance with law, hereby depose and state:

That I am one of the heirs of late Spouses Juanito Dalida and Pilar Adriatico, owners of the following parcels of
land, to wit:

4. A parcel of land known as Lot 4, CCS-09-08-000048, covered by Original Certificate of Title No. P-
27641 located at Milad, Polanco, Zamboanga del Norte, containing an area of 48,184 square meters.

5. A parcel of land known as Lot 5, CCS-09-08-000048, covered by Original Certificate of Title No. P-
27638 located at Milad, Polanco, Zamboanga del Norte, containing an area of 49,998 square meters.

6. A parcel of land known as Lot 1, CCS-09-08-000048, covered by Original Certificate of Title No. P-
27639 located at Milad, Polanco, Zamboanga del Norte, containing an area of 49,998 square meters.

That since the death of my parents, I together with my siblings tried to find the owner’s copies of the title of
abovementioned parcels of land and could not locate it anymore;

That despite effort to recover the same but it was naught.

That I considered it as totally lost.

That I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for the purpose
of attesting to the loss of the said owner’s copies of the certificates of title.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2021, at Dipolog
City.

DIONISIO A. DALIDA

(Affiant)

ID#_______________________

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at Dipolog City.
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, JULIETO N. BAJAMUNDE, of legal age, Filipino, married, a resident of Bayang, Gulayon, Dipolog City,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of my Automated Teller Machine(ATM) card issued by Landbank-
Dipolog City with Account No.0516-2853-11.

That on October 1, 2021, while I was transiting towards my office at NIA, I found out my said ATM
card was lost;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said ATM card issued by Landbank.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2021, at
Dipolog City.

JULIETO N. BAJAMUNDE
(Affiant)
Driver’s License#J01-87-006040
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at Dipolog City.

Doc. No.

Page No.

Book No.

Series of 2021
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, JIMMY SUYA PITRE, of legal age, Filipino, single, a resident of Obay, Polanco, Zamboanga del Norte
after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of Plate Number issued by Land Transportation Office for a Honda
XRM with Plate Number 2694 SA under my name;

That on October 2, 2021, I discovered that the said Plate number was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said Plate number and thereafter requesting replacement
of the same.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2021, at
Dipolog City.

JIMMY S. PITRE
(Affiant)
TIN#381-4220937
With photo
SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at Dipolog City.

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, FRENCITO G. PASIGNA, of legal age, Filipino, a resident of VCH, Obay,

Polanco, Zamboanga del Norte after having been duly sworn in accordance
with law, hereby depose and state:

That I am holder and possessor of Certification of Transfer Tax Fee with OR

No. 8485211 and OR No. 8485213 dated September 16, 2021 issued by
Treasurer’s Office of Province of Zamboanga del Norte;

That on October 5, 2021, I discovered that the official receipts were lost,
and could not be found;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost;

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

foregoing statements and for the purpose of attesting to the loss of the said
official receipts.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2021, at Dipolog City.

FRENCITO G. PASIGNA
(Affiant)
OSCA ID#18-03592, Polanco,ZN
SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at
Dipolog City.

DOC.NO.

PAGE NO.

BOOK NO.

SERIES OF 2021

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, JOSE DAN B. MERCADO, of legal age, Filipino, married, a resident of

Turno, Dipolog City, after having been duly sworn in accordance with law,
hereby depose and state:

That I am a holder and possessor of a Passbook with Account No.

001231004903 issued by Katipunan Bank-Dipolog City Branch under my
name;

That in September 2020, while I was trying to look for the said Passbook
from where I kept it, I found out that the Passbook was lost, and could not
be found;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost;

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

foregoing statements and for the purpose of attesting to the loss of the said
Passbook, and request the replacement of the said passbook.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2021, at Dipolog City.
 JOSE DAN B. MERCADO
(Affiant)
PRC ID#1075655 valid until 10/17/2022
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at

Dipolog City.

Doc No. _____

Page No. _____
Book No. ____
Series of 2021

FRENCITO G. PASIGNA, of legal age, Filipino, a resident of VCH, Obay, Polanco, Zamboanga del Norte

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, EARL JHOELLE BOCALA BANGOT, of legal age, Filipino, married, a resident of North Curvada,
Galas,Dipolog City, Zamboanga del Norte after having been duly sworn in accordance with law,
hereby depose and state:

That I am holder and possessor of a driver’s license with number J01-09-003111 issued by Land
Transportation Office(LTO).

That on September 21, 2021, I discovered that driver’s license which I usually put in my bag was lost,
and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said driver’s license issued by LTO.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2021, at
Dipolog City.
 EARL JHOELLE B. BANGOT
(Affiant)
Driver’s License#J01-09-003111
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at Dipolog City.

DOC.NO.

PAGE NO.

BOOK NO.

SERIES OF 2021

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, LLOYD R. PASCUAL, of legal age, Filipino, single/married, a resident of Dapitan City, Zamboanga del
Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a liaison officer of Gud Moto Trading Inc. and holder and possessor of PNP Clearance and
Certificate of Stock Reported for motor vehicle with motor number BC175AEBH1670 and Chassis
No.BC175H-BBO291.

That on September 20, 2021, I discovered that folder containing the PNP Clearance and Certificate of
Stock Reported of the said vehicle was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said PNP Clearance and Certificate of Stock Reported.
IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2021, at
Dipolog City.

LLOYD R. PASCUAL
(Affiant)
Driver’s License#J01-05-002100

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at Dipolog City.

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, JOCELYN S. BREGOLI, of legal age, Filipino, single, a resident of

Macleodes, Polanco, Zamboanga del Norte, after having been duly sworn in
accordance with law, hereby depose and state:

That I am a holder and possessor of a Unified Multipurpose Identification

Card(UMID) issued by Government Service Insurance System(GSIS);

That l received my UMID card and when I tried to look for it but it was
nowhere to be found thus I considered it as lost;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost;
As such, I am executing this Affidavit of Loss to attest to the truth of the
foregoing statements and for the purpose of attesting to the loss of the said
UMID card and request the replacement of the said card.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2021, at Dipolog City.

JOCELYN S. BREGOLI
(Affiant)
ID#____________________
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at

Dipolog City.

Doc.No.

Page No.

Book No.

Series of 2021

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, FLORRYBEL C. BIOLANGO, of legal age, Filipino, single, resident of Purok Antonio Luna, Aliguay,
Dapitan City, Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and
state:

That I am the granddaughter and representative of all heirs of PELAGIO BIOLANGO, registered owner of a
parcel of land, more particularly described as follows:
A parcel of land known as Lot No.5022,GSS-1354, covered by Original Certificate of Title No. P-728 with
CLOA Award No.00042988 located at Galingon, Tampilisan, Zamboanga del Norte with an area of ninety-four
thousand four hundred seventy-four(94,474) square meters.

That my father is Segundino Biolango and his brother Pedro Biolango, who is now dead, who had possession of
the owner’s copy of the title but it was lost due to fire;

That despite effort to recover the same but it was naught.

That I considered it as totally lost.

That I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for the purpose
of attesting to the loss of the said Original Certificate of Title No.P-728.

IN WITNESS WHEREOF, I have hereunto affixed my signature this 5th day of Augsut 2021, at Dipolog City.

FLORRYBEL C. BIOLANGO

(Affiant)

Voters ID#72010029BA0284FCB20000-3

SUBSCRIBED AND SWORN to before me this 5th day of August 2021, at Dipolog City.

DOC.NO. 3692

PAGE NO.82

BOOK NO.XI

SERIES OF 2021

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS
I, JIMMY B. GALLEPOSO, of legal age, Filipino, widower, a resident of
Bagting,Dapitan City, Zamboanga del Norte after having been duly sworn in
accordance with law, hereby depose and state:

That I am representative of Jildee Galleposo, holder and possessor of

updated Official Receipt(OR) and Certificate of Registration(CR) for the
motor vehicle with Plate No.4209 JC, issued by LTO.

That in September 2021, I discovered that folder containing the official

receipt and Certificate of Registration from LTO was lost, and could not be
found;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost;

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

foregoing statements and for the purpose of attesting to the loss of the said
official receipt and certificate of registration issued by LTO.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2021, at Dipolog City.

JIMMY B. GALLEPOSO
(Affiant)
OSCA ID#010288
Issued at Dapitan City

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at

Dipolog City.

Doc. No.

Page No.

Book No.

Series of 2021
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, NANCY C. LAURQUE, of legal age, Filipino, a resident of Pob.North, Polanco, Zamboanga del Norte
after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of an original copy of e-Certificates Authorizing Registration(eCARs)

issued issued by Bureau of Internal Revenue with No. eCR-C-2019-091-012391-M and C-2019-091-
012392-M for the taxes.

That last week of July 2021, while I was trying to look for my said eCARs from my file folder, then I
found out that the eCARs were lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said eCAR and reissuance of the same and claiming the
documents at the Bureau of Internal Revenue anent to the slip.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2021, at
Dipolog City.

NANCY C. LAURQUE
(Affiant)
ID#____________________
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at Dipolog City.

DOC. NO. _____

PAGE NO._____
BOOK NO.____
SERIES OF 2021
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, DOLLY ANN T. BUNDAON, of legal age, Filipino, single, a resident of Bandera, Polanco, Zamboanga
del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am the buyer/holder and possessor of an original BIR stamped Deed of Absolute Sale of Land
notarized by Atty Eulogio L. Lagudas,Jr under Doc. No. 2746, Page No. 105, Book No. 41, Series of
2019. That however after it was stamped by the BIR, the said original copy of the Deed of Sale duly
stamped by BIR was lost.

That I tried to locate the said document, but it could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said BIR stamped Deed of Absolute Sale.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2021, at
Dipolog City.

DOLLY ANN T. BUNDAON

(Affiant)
Voters ID#7210-0019B-G1680DTB20000
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at Dipolog City.

Doc. No.

Page No

Book No

Series of 2021
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, LLOYD R. PASCUAL, of legal age, Filipino, single/married, a resident of Dapitan City, Zamboanga del
Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a liaison officer of Gud Moto Trading Inc. and holder and possessor of updated Official
Receipt(OR) with OR No.1863501183 for Motor vehicle with CR No.13779807-6, issued by LTO.

That on August 19, 2021, I discovered that folder containing the official receipt from LTO was lost, and
could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said official receipt issued by LTO.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2021, at
Dipolog City.

LLOYD R. PASCUAL
(Affiant)
Driver’s License#J01-05-002100

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at Dipolog City.
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, HIRA DEE ASAY DAAROL, of legal age, Filipino, single, a resident of Sta. Isabel, Dipolog City,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of my Automated Teller Machine(ATM) card issued by Landbank-
Dipolog City with Account No.0517-1985-44.

That on September13, 2021, after I withdrawn from an ATM machine I found out my said ATM card
was lost;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said ATM card issued by Landbank.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2021, at
Dipolog City.

HIRA DEE ASAY DAAROL

(Affiant)
Driver’s License#J01-21-200577
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at Dipolog City.

Doc. No.
Page No.

Book No.

Series of 2021

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, MARGARITA A. BAQUILAN of legal age, Filipino, single, a resident of San Vicente, Katipunan,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of an original copies of Deed of Absolute Sale notarized by Ivo M.
Mandantes under Doc. No.1600, Page No. 73, Book No.IX, Series of 2021 which was duly stamp by
BIR at the back of said documents after payment of taxes.

That last week of August 2021, while I was trying to look for my said documents, then I found out that
original copies with BIR stamp were lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said original copies of deeds with BIR stamp and reissuance
of certified copies.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2021, at
Dipolog City.

MARGARITA A. BAQUILAN
(Affiant)
 Brgy San Dionisio, Paranaque City ID#1272250-0
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at Dipolog City.

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, GLENDA R. DEL VALLE, of legal age, Filipino, a resident of Turno, Dipolog

City, after having been duly sworn in accordance with law, hereby depose
and state:

That I am a holder and possessor of a Passbook issued by 1 st Valley Bank-

Dipolog City Branch under my name;

That in first week of September 2021, while I was trying to look for the said
Passbook from where I kept it, I found out that the Passbook was lost, and
could not be found;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost;

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

foregoing statements and for the purpose of attesting to the loss of the said
Passbook, and request the replacement of the said passbook.
IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of
__________ 2021, at Dipolog City.

GLENDA R. DEL VALLE

(Affiant)
TIN#938-746-606
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at

Dipolog City.

Doc No. _____

Page No. _____
Book No. ____
Series of 2021

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ALDASIR L. IPAH, of legal age, Filipino, married, a resident of Piao, Roxas, Zamboanga del Norte
after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of my Automated Teller Machine(ATM) card issued by MetroBank
for my payroll as employee of Ace Promotion and Marketing Corporation.

That on September 4, 2021, my said ATM card was lost;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said ATM card issued by Metrobank.
IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2021, at
Dipolog City.

ALDASIR L. IPAH
(Affiant)
Driver’s License#J01-05-003110
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at Dipolog City.

Doc. No.

Page No.

Book No.

Series of 2021

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, REDZIL PRIETO OLIVO, of legal age, Filipino, single, a resident of Purok 2,

Talairon, Oroquieta City after having been duly sworn in accordance with
law, hereby depose and state:

That I am a holder and possessor of a Philippine Passport issued by the

Department of Foreign Affairs.

That sometime in year 2015, I found that my said passport was missing;
That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
passport.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2021, at Dipolog City.

REDZIL PRIETO-OLIVO
(Affiant)
Driver’s License#K12-20-001132 until 2024/08/15
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at

Dipolog City.

Doc. No.

Page No.

Book No.

Series of 2021

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ROGELIO F. MAURICIO, of legal age, Filipino, married, a resident of Sitog, Katipunan, Zamboanga del
Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am holder and possessor of an identification card as retired member of the Armed Forces of the
Philippines;
That recently, I discovered that an identification card which I usually put in my file folder of
documents was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said identification card.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2021, at
Dipolog City.

ROGELIO F. MAURICIO
(Affiant)
597347 PA
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at Dipolog City.

DOC.NO.

PAGE NO.

BOOK NO.

SERIES OF 2021

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, REGIE SANGCOM CANSANG, of legal age, Filipino, single, a resident of Lapu-lapu St., Estaka,Dipolog
City, Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and
state:

That I am holder and possessor of a driver’s license with number N04-05-006445 issued by Land
Transportation Office(LTO).
That on September 5, 2021, I discovered that driver’s license which I usually put in my wallet was
lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said driver’s license issued by LTO.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2021, at
Dipolog City.

REGIE SANGCOM CANSANG

(Affiant)
Driver’s License#N04-05-006445
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at Dipolog City.

DOC.NO.

PAGE NO.

BOOK NO.

SERIES OF 2021

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, EXPEDITO ELUMBARING of legal age, Filipino, widower, a resident of Lingasad, Polanco, Zamboanga
del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of a Senior Citizen’s ID issued by Office of the Senior Citizen’s Affairs.

That sometime last week, I discovered that my wallet containing the said identification card was lost;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.
As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said Senior Citizen’s ID issued by OSCA.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2021, at
Dipolog City.

EXPEDITO ELUMBARING
(Affiant)
CTC ID#CCI201917739597
Issued at MTO Polanco, Zamboanga del Norte

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at Dipolog City.

Doc. No.

Page No.

Book No.

Series of 2021

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT

I, TEODORVINE B. EVARDO, of legal age, Filipino, widow, a resident of Central Barangay, Dipolog City,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am an heir of Eutiquiano G. Sagario who died on May 30, 1974 at Dipolog City

That all of his estate tax and other taxes were duly paid before the Bureau of Internal Revenue in 1974.

That the original copy of Estate and Inheritance Tax Return duly filed and paid was issued by the Bureau of
Internal Revenue(BIR)

That however upon processing for titling, the Certificate Authorizing Registration(CAR) was not available and
by the advent of digitalization and computeration, eCAR is now necessary;
As such, I am executing this Affidavit to attest to the truth of the foregoing statements and for the purpose of
attesting to the circumstances of the said eCAR and reissuance of the same and claiming the documents at the
Bureau of Internal Revenue anent thereto and/or to process the title before Register of Deeds.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2021, at Dipolog
City.

TEODORVINE S. EVARDO
(Affiant)
OSCA ID#12007-Dipolog City
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at Dipolog City.

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, RODOLFO C. DALMAN of legal age, Filipino, married, a resident of Gen Luna St. Estaka, Dipolog City
after having been duly sworn in accordance with law, hereby depose and state:
That I am a holder and possessor of an original copy of e-Certificates Authorizing Registration(eCARs)
issued issued by Bureau of Internal Revenue with No. eCR201800001977 and eCR2018000019778 for
the estate taxes.

That last week of July 2020, while I was trying to look for my said eCARs from my file folder, then I
found out that the eCARs were lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said eCAR and reissuance of the same and claiming the
documents at the Bureau of Internal Revenue anent to the slip.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2021, at
Dipolog City.

RODOLFO C. DALMAN
(Affiant)
TIN#949-091-870
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at Dipolog City.

DOC. NO. _____

PAGE NO._____
BOOK NO.____
SERIES OF 2021

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, RODELYN B. ENTOMA, of legal age, Filipino, widow, a resident of Dampalan, Dapitan City,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of a Philippine Passport issued by the Department of Foreign Affairs.

That sometime in year 2018, I submitted my passport to a manpower agency which supposedly
processed my application for work abroad, however the said agency later closed and did not return
my passport;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said passport.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2021, at
Dipolog City.
 RODELYN B. ENTOMA
(Affiant)
Voters ID#7202-0026A-K2670RBE20000-9
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at Dipolog City.

Doc. No.

Page No.

Book No.

Series of 2021

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ANTHON JOHN S. SORIANO, of legal age, Filipino, single/married, a resident of Dipolog City,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am holder and possessor of updated Official Receipt(OR) for Motor vehicle described as HONDA
FIT with Plate Number JEN 828, issued by LTO.

That on August 19, 2021, I discovered that folder containing the official receipt from LTO was lost, and
could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;
As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said official receipt issued by LTO.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2021, at
Dipolog City.

ANTHON JOHN S. SORIANO

(Affiant)
ID#____________________
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at Dipolog City.

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

We: ORLEANS B. MIRAFUENTES and LOYALTY M. SORIA, both of legal age,

both Filipinos, both residents of Polanco, Zamboanga del Norte, after
having been duly sworn in accordance with law, hereby depose and state:

That we are co-holders and co-possessors of a Passbook with No.10A002625

issued by Rural Bank of Rizal-Polanco Branch under our name;
That in first week of August 2021, while we were trying to look for the said
Passbook from where we kept it, we found out that the Passbook was lost,
and could not be found;

That despite effort to recover the same but it was naught. Hence, we
considered it as totally lost;

As such, we are executing this Affidavit of Loss to attest to the truth of the
foregoing statements and for the purpose of attesting to the loss of the said
Passbook, and request the replacement of the said passbook.

IN WITNESS WHEREOF, we have hereunto affixed our signatures this ___ day
of __________ 2021, at Dipolog City.

LOYALTY M. SORIA ORLEANS B. MIRAFUENTES

(Heir/Waiver) (Affiant)
Driver’s License#J01-08-003605 Driver’s License#J01-15-001546

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at

Dipolog City.

Doc No. _____

Page No. _____
Book No. ____
Series of 2021

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, KYLE M. GABUCAN, of legal age, Filipino, single, a resident of Rizal Street, Polanco,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose
and state:
That I am a holder and possessor of a Driver’s License Identification Card(ID) and Driver’s
License of my girlfriends Ava Joanne Celocia issued by the Land Transportation Office.

That on August 22, 2021, my wallet containing my LTO Driver’s License and Driver’s License of
Ava Joanne Selocia was lost;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements
and for the purpose of attesting to the loss of the said my Driver’s License ID and Ava Joanne
Celocia.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2021,
at Dipolog City.

KYLE M. GABUCAN
(Affiant)
ID#________________

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at Dipolog City.

Doc. No.

Page No.

Book No.

Series of 2021

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, JUNSEL ABELLERIA JARMIN, of legal age, Filipino, single, a resident of Sto.Nino, Polanco, Zamboanga
del Norte after having been duly sworn in accordance with law, hereby depose and state:
That I am holder and possessor of Philhealth Identification card.

That in the second week of August 2021, my wallet containing the said Philhealth ID was lost;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said Philhealth ID .

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2021, at
Dipolog City.

JUNSEL ABELLERIA JARMIN

(Affiant)
TIN#600-975-621

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at Dipolog City.

Doc. No.

Page No.

Book No.

Series of 2021

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT

I, ARNEL E. ENOY of legal age, Filipino, married, a resident of Bandera, Polanco, Zamboanga del Norte after
having been duly sworn in accordance with law, hereby depose and state:
That I am a holder and possessor of an original copy of e-Certificates Authorizing Registration(eCARs) issued
issued by Bureau of Internal Revenue with No. 00004549 and No.00004550 for the taxes.

That the original copy of eCARs issued by the Bureau of Internal Revenue(BIR) was submitted to Register of
Deeds(ROD);

That however upon processing for transfer of title before the Register of Deeds, the original copy was not
anymore in my possession because it was already with ROD;

As such, I am executing this Affidavit to attest to the truth of the foregoing statements and for the purpose of
attesting to the circumstances of the said eCAR and reissuance of the same and claiming the documents at the
Bureau of Internal Revenue anent thereto and/or to process the title before Register of Deeds.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2021, at Dipolog
City.

ARNEL E. ENOY
(Affiant)
ID#___________________
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at Dipolog City.

Doc No. 1418 IVO M. MANDANTES,CPA

Page No. 58 NOTARY PUBLIC FOR ZAMBOANGA DELNORTE
Book No. 74 VALID UNTIL 12-31-2021
Series of 2021 COMMISSION NO.SN:ZDN-DPL-013-2020
PTR NO.1945342,1/02/2020
IBP NO.095495,11/22/2019 for 2020
ATTORNEY’S ROLL NO. 65014
LAPU-LAPU ST. DIPOLOG CITY

DOC. NO. 1418

PAGE NO.58
BOOK NO.74
SERIES OF 2021

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, LLOYD R. PASCUAL, of legal age, Filipino, single/married, a resident of Dapitan City, Zamboanga del
Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a liaison officer of Gud Moto Trading Inc. and holder and possessor of updated Official
Receipt(OR) for Motor vehicle with CR No.348271011, issued by LTO.

That on August 19, 2021, I discovered that folder containing the official receipt from LTO was lost, and
could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said official receipt issued by LTO.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2021, at
Dipolog City.

LLOYD R. PASCUAL
(Affiant)
Driver’s License#J01-05-002100

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at Dipolog City.
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, LILY T. PORACAN, of legal age, Filipino, single/married, a resident of Estaka, Dipolog City,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of my Automated Teller Machine(ATM) card issued b y Union Bank
of the Philippines.

That on August 12, 2021, my said ATM card was lost;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said ATM card issued by Union Bank of the Philippines.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2021, at
Dipolog City.

LILY T. PORACAN
(Affiant)
OSCA ID#16457
Issued by Dipolog City

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at Dipolog City.
Doc. No.

Page No.

Book No.

Series of 2021

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ALEX L. EMPEYNADO, of legal age, Filipino, a resident of San Miguel, Polanco, Zamboanga del Norte
after having been duly sworn in accordance with law, hereby depose and state:

That I am holder and possessor of Certificate of Registration(CR) and an Official Receipt(OR) for the
motor vehicle with the following descriptions:

Make:SUZUKI Body Type:DROPSIDE

CR No.:150557945 Plate No.:GNL539

Series:with Canopy

That on August 10, 2021, I discovered that the original copies of CR and OR were lost;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said CR and OR.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2021, at
Dipolog City.

ALEX L. EMPEYNADO
(Affiant)
 Driver’s License#J01-84-015871
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at Dipolog City.

Doc. No.

Page No.

Book No.

Series of 2021

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, REIL HAZZIN B. BICOY, Filipino, of legal age, married, and a resident of

Sto.Tomas, Mutia, Zamboanga del Norte after having been duly sworn in
accordance with law, hereby depose and state:

That I am a holder and possessor of an official receipt issued by MLhuillier

for a pawned jewelry identified as 1 YG PUL DEF 6.6g 18K with Receipt No.
PTN 0553-2021-00163 in the amount of P11,000.00 pawned on February
10,2021.

That in the last week of March, 2021, I found out that my receipt was lost, I
tried to locate the receipt but it was really lost, and could not be found;
That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
official receipt of MLhuillier.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2021, at Dipolog City.

REIL HAZZIN B. BICOY

(Affiant)
DILG ID#097208016-07
With phot

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at

Dipolog City.

Doc. No.__
Page No.__
Book No.__
Series of 2021

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, GEORGE VILLARUEL DE JESUS, of legal age, Filipino, married, a resident of Sta. Cruz, Dapitan City,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:
That I am a holder and possessor of a cellular phone with Sim card under SMART with number
09684250892.

That on August 8, 2021, I discovered that my said cellular phone with simcard inside was lost, and
could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said cellular phone with sim card and thereafter requesting
replacement of the same.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2021, at
Dipolog City.

GEORGE VILLARUEL DE JESUS

(Affiant)
UMID ID#CRN-0009-1622742-7
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at Dipolog City.

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS
I, TITA T. MISARIO, of legal age, Filipino, married, resident of Lapayanbaja, Polanco, Zamboanga del Norte
after having been duly sworn in accordance with law, hereby depose and state:

That I am the co-owner and spouse of Petronilo Misario, owner of a parcel of land, more particularly described
as follows:

A parcel of land known as Lot 5312-B-6, Psd-09-023647, covered by Transfer Certificate of Title No. T-55432
located at Lapayanbaja, Polanco, Zamboanga del Norte.

That I have misplaced the owner’s copy of the title and could not locate it anymore;

That despite effort to recover the same but it was naught.

That I considered it as totally lost.

That I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for the purpose
of attesting to the loss of the said Transfer Certificate of Title No.T-55432.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2021, at Dipolog
City.

TITA T. MISARIO

(Affiant)

OSCA ID#18-03376

Issued at Polanco, Zamboanga del Norte

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at Dipolog City.
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, FLORRYBEL C. BIOLANGO, of legal age, Filipino, single, resident of Purok Antonio Luna, Aliguay,
Dapitan City, Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and
state:

That I am the granddaughter of PELAGIO BIOLANGO, registered owner of a parcel of land, more particularly
described as follows:

A parcel of land known as Lot No.5022,GSS-1354, covered by Original Certificate of Title No. P-728 located at
Galingon, Tampilisan, Zamboanga del Norte with an area of ninety-four thousand four hundred seventy-
four(94,474) square meters.

That my father is Segundino Biolango and his brother Pedro Biolango who had possession of the owner’s copy
of the title but it was lost due to fire;

That Pedro Biolango was long dead;

That despite effort to recover the same but it was naught.

That I considered it as totally lost.

That I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for the purpose
of attesting to the loss of the said Original Certificate of Title No.P-728.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2021, at Dipolog
City.

FLORRYBEL C. BIOLANGO

(Affiant)

Voters ID#72010029BA0284FCB20000-3

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at Dipolog City.
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT

I, NANITH LABASTIDA -CARBON, of legal age, Filipino, married to Rommel V. Carbon, a resident of
Olingan, Dipolog City, Zamboanga del Norte after having been duly sworn in accordance with law, hereby
depose and state:

That I am a holder and possessor of an original copy of e-Certificate Authorizing Registration(eCAR) issued
issued by Bureau of Internal Revenue with No. eCR201800369881 for the estate tax of late Sergia Bahian.

That the original copy of eCARs issued by the Bureau of Internal Revenue(BIR) was submitted to Register of
Deeds(ROD);

That however upon processing for transfer of title before the Register of Deeds, the original copy was not
anymore in my possession because it was already with ROD;

As such, I am executing this Affidavit to attest to the truth of the foregoing statements and for the purpose of
attesting to the circumstances of the said eCAR and reissuance of the same and claiming the documents at the
Bureau of Internal Revenue anent thereto and/or to process the title before Register of Deeds.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2021, at Dipolog
City.

NANITH LABASTIDA-CARBON
(Affiant)
ID#____________________
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at Dipolog City.

DOC. NO. ___

PAGE NO.__
BOOK NO.___
SERIES OF 2021
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ROSELO G. BALUCAN, of legal age, Filipino, married, a resident of St. Nino, Labason, Zamboanga del
Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of an official receipt with OR No.8470723 issued by the Provincial
Government of Zamboanga del Norte for the taxes of the property under the name of my father
Jaime Embol Balucan;

That on August 2, 2021, I discovered that folder containing the said document was lost, and could not
be found. That the lost could be due to fire;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said Official Receipt No.8470723.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2021, at
Dipolog City.

ROSELO G. BALUCAN
(Affiant)
Driver’s License#J01-10-00402
Until 2023/02/23

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at Dipolog City.

Doc. No.

Page No

Book No

Series of 2021
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, FEORIDIN JASON L. ELUMBARING, of legal age, Filipino, single/married, a resident of Sunset

Boulevard, Sta. Cruz, Dapitan City, Zamboanga del Norte after having been duly sworn in accordance
with law, hereby depose and state:

That I am a holder and possessor of Diploma and other related documents as proof that I was a High
School Graduate issued by Zamboanga del Norte School of Arts and Trade(ZNSAT) for the year 1997;

That on July 27, 2021, I discovered that folder containing the said document was lost, and could not
be found. That the lost could be due to fire;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said Diploma.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2021, at
Dipolog City.

FEORIDIN JASON L. ELUMBARING

(Affiant)
Driver’s License#J01-04-002729
Until 2023/11/25

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at Dipolog City.

Doc. No.

Page No

Book No

Series of 2021
Republic of the Philippines)
City of Dipolog . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, FELIX M. CELICIOUS,JR, of legal age, Filipino, married to Soledad M.

Celicious, resident of Biasong, Dipolog City after having been duly sworn in
accordance with law, hereby depose and state:

That I am holder and possessor of an Official Receipt(OR) for my motor

vehicle with CR No.348192460, Engine No.JF78E7132323, Chassis
No.MH1JF7875KK132637;

That sometime July 2021, my wallet containing the said Official Receipt(OR)
for the said motor vehicle was lost;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost.

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

foregoing statements and for the purpose of attesting to the loss of the said
Official Receipt(OR) for the said motor vehicle.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2021, at Dipolog City.

FELIX M. CELICIOUS,JR.
(Affiant)
OSCA ID#7972

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at

Dipolog City.

Doc. No.

Page No.
Book No.

Series of 2021

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, GIRLIE CLARET DUHAYLUNGSOD, of legal age, Filipino, married, a resident

of Igot, Turno, Dipolog City, after having been duly sworn in accordance with
law, hereby depose and state:

That I am a holder and possessor of an ATM Cash Card issued by Landbank

of the Philippines for 4Ps beneficiary of DSWD

That in first week of July 2021, while I was trying to look for the said ATM
cash card from where I kept it, I found out that the ATM card was lost, and
could not be found;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost;

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

foregoing statements and for the purpose of attesting to the loss of the said
ATM Cash card, and request the replacement of the said Landbank ATM
Cash Card.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2021, at Dipolog City.

GIRLIE CLARET DUHAYLUNGSOD

(Affiant)
 Voters ID#PRN M83180309420P
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at

Dipolog City.

Doc No. _____

Page No. _____
Book No. ____
Series of 2021

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, RONINIE BAXTER MASSIE HAMPTON, of legal age, British citizen, married

to Anita Comoyong Hampton, a resident of Purok Tunggo, Minaog, Dipolog
City, after having been duly sworn in accordance with law, hereby depose
and state:

That I am giving my full authority to Mr. Ralph Carlo D. Carabio as my

representative to claim my permanent I-card with an ACR Number
G0000238542 in the Bureau of Immigration located at Cebu City;

That sometime April 2021, the claim stab or slip used to claim the said
permanent I-car at Bureau of Immigration at Cebu City was mixed up with
the clothes for washing and thus it was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost;

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

foregoing statements and for the purpose of attesting to the loss of the said
permanent I-card.
IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of
__________ 2021, at Dipolog City.

RONNIE BAXTER MASSIE HAMPTON

(Affiant)
UK Great Britain and Northern Irelan Passport No. 538267436
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at

Dipolog City.

Doc No. _____

Page No. _____
Book No. ____
Series of 2021

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS
I, MARIA WILFREDA S. ORANING, of legal age, Filipino, single, a resident of
Purok 8, Biasong, Dipolog City, after having been duly sworn in accordance
with law, hereby depose and state:

That I am a holder and possessor of a Passbook issued by KMBI-Dipolog City

Branch under my name;

That in first week of July 2021, while I was trying to look for the said
Passbook from where I kept it, I found out that the Passbook was lost, and
could not be found;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost;

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

foregoing statements and for the purpose of attesting to the loss of the said
Passbook, and request the replacement of the said passbook.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2021, at Dipolog City.

MARIA WILFREDA S. ORANING

(Affiant)
Voters ID#72020033AF239MSO20000
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at

Dipolog City.

Doc No. _____

Page No. _____
Book No. ____
Series of 2021
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, DOVEE MARIE B. GAMOROT, of legal age, Filipino, married, a resident of Miputak, Dipolog City,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of a franchise or Motorized Tricycle Operator’s Permit(MTOP), with
the following details:

Make:Yamaha Motor No.:2JC1025272 Chassis No.:2JC1025744

Registration No.:CR#252047810 Plate No.TP-090807-18 DPLG.NO.:2020-1122

MTOP Expiry Date:July 2021

That on July 14, 2021, I discovered that the original copy of the said franchise or MTOP was lost, and
could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said franchise or MTOP and thereafter requesting
replacement of the same.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2021, at
Dipolog City.

DOVEE MARIE B. GAMOROT

(Affiant)
Driver’s License#J01-07-000086
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at Dipolog City.
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, MYLYN M. BUSTALIÑO, of legal age, Filipino, single, a resident of Olingan, Dipolog City, Zamboanga
del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a personnel of FORD-Dipolog City Branch;

That I am a holder and possessor of Plate Number issued by Land Transportation Office for a Ford
Everest Ambinete 2.2 4x2 AT with Plate Number NDE 4630 under the name of registered owner
Honorio N. Sakall;

That the said unit was used as company’s demostation unit to prospective customers;

That the papers and other identification documents of the said vehicle arrived only in June 2021;

That on the same month of June 2021, I discovered that the said Plate number was lost, and could not
be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said Plate number and thereafter requesting replacement
of the same.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2021, at
Dipolog City.

MYLYN M. BUSTALIÑO
(Affiant)
Driver’s License#J01-18-006520
Valid until 2023/08/16
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at Dipolog City.

Doc. No.___
Page No.____
Book No.____
Series of 2021

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, VILMA V. LORCA, of legal age, Filipino, single/married, a resident of San Pedro, Polanco, Zamboanga
del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of a Sim card under Globe with number 09778019109.

That sometime first week of July 2021, I discovered that my said simcard was lost, and could not be
found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said sim card and thereafter requesting replacement of the
same.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2021, at
Dipolog City.

VILMA LORCA
 (Affiant)
PRC ID#0673089
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at Dipolog City.

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ALYSSA JOIE R. COLATA, Filipino, of legal age, single, and a resident of 041 Bayabas,
Sangkol, Dipolog City, Zamboanga del Norte after having been duly sworn in accordance with
law, hereby depose and state:

That I am a holder and possessor of an official receipt issued by MLhuillier for a pawned jewelries, to
wit: I YG Necklace YISS DED YI 101 4.50 G and 1 YG Pendant DEF YT 104 2.80G with Receipt No. 0553-
2021-00438 in the amount of P14,000.00 pawned on March 13,2021.

That on June 24, 2021, I found out that my receipt was lost, I tried to locate the receipt but it was
really lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.
As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said official receipt of MLhuillier.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2021, at
Dipolog City.

ALYSSA JOIE R. COLATA

(Affiant)
Driver’s License#J01-18-000915
Until 2022/06/12
With phot

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at Dipolog City.

Doc. No.__
Page No.__
Book No.__
Series of 2021

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ANNE MAUREEN OCAMIA MAPUTOL, of legal age, Filipino, married, a resident of Purok African
Daisy, Anastacio, Polanco, Zamboanga del Norte after having been duly sworn in accordance with
law, hereby depose and state:

That I am holder and possessor of Social Security System(SSS) Identification card.

That on July 5,2021, my wallet containing the said SSS ID was lost;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.
As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said SSS ID.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2021, at
Dipolog City.

ANNE MAUREEN OCAMIA MAPUTOL

(Affiant)
Postal ID#PRNM83210261403P

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at Dipolog City.

Doc. No.

Page No.

Book No.

Series of 2021

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ROLAN NIEVES MAPUTOL, of legal age, Filipino, married, a resident of Purok African Daisy,
Anastacio, Polanco, Zamboanga del Norte after having been duly sworn in accordance with law,
hereby depose and state:
That I am holder and possessor of Driver’s License and an Official Receipt(OR) for the said license and
Social Security System(SSS) Identification card.

That on July 5,2021, my wallet containing the said Drivers License and an Official Receipt(OR) for the
said license, SSS ID was lost;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said Drivers License and an Official Receipt(OR) for the said
license, and SSS ID.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2021, at
Dipolog City.

ROLAN NIEVES MAPUTOL

(Affiant)
Postal ID#PRNM83210261411P

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at Dipolog City.

Doc. No.

Page No.

Book No.

Series of 2021

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, JESSAN T. LACAY, of legal age, Filipino, single/married, a resident of

Villahermosa, Polanco, Zamboanga del Norte, after having been duly sworn
in accordance with law, hereby depose and state:

That I am a holder and possessor of the Purchase Order with reference

number CSW#178350 issued by LP City Central Supermarket, Dipolog City
for delivery of several orders of LP City Central-Supermarket;

That I am a coordinator of Unilever RFM Ice Cream, Inc. Selecta;

That on July 9, 2021, while I tried to look for the said Purchase Order on the
goods delivered to LP City Central –Supermarket, I found out that the
second page of the Original Copy of the said Purchase Order was lost, and
could not be found;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost;

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

foregoing statements and for the purpose of attesting to the loss of the
second page of said Purchase Order CSW#178350.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2021, at Dipolog City.

JESSAN T. LACAY
(Affiant)
DILG ID#097210029-06-Villahermosa, Polanco, ZN
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at

Dipolog City.

Doc No. _____

Page No. _____
Book No. ____
Series of 2021

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS
I, ARACELI E. CAYETANO, of legal age, Filipino, widow, a resident of Dicayo, Katipunan,Zamboanga del
Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of Eastwest Rural Bank(Eastwest)-Dipolog City Branch Automated
Teller Machine(ATM) card;

That sometime April 2021, I found out that my said ATM card was lost;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said Eastwest ATM card.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2021, at
Dipolog City.

ARACELI E. CAYETANO
(Affiant)
Driver’s License#J01-99-028827
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at Dipolog City.

Doc. No.

Page No.

Book No.

Series of 2021

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS
I, KIM D. EMPEYNADO, of legal age, Filipino, single, a resident of Poblacion North, Polanco,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of a Sim card under SMART with Serial Number 0317230503494840
and with number 09126323595 .

That on July 4, 2021, I discovered that my said simcard was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said sim card and thereafter requesting replacement of the
same.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2021, at
Dipolog City.

KIM D. EMPEYNADO
(Affiant)
Driver’s License#J01-18-002096
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at Dipolog City.

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS
I, TITO SOLIVA TABONIAG, of legal age, Filipino, married, a resident of 759 South Proper Galas,
Dipolog City, Zamboanga del Norte after having been duly sworn in accordance with law, hereby
depose and state:

That I am holder and possessor of Drivers License with Number J01-95-018819 and an Official
Receipt(OR) for the said license, SSS ID, Philhealth ID and RCBC ATM card.

That on July 5,2021, my wallet containing the said Drivers License with Number J01-95-018819 and an
Official Receipt(OR) for the said license, SSS ID, Philhealth ID and RCBC ATM card was lost;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said Drivers License with Number J01-95-018819 and an
Official Receipt(OR) for the said license, SSS ID, Philhealth ID and RCBC ATM card .

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2021, at
Dipolog City.

TITO SOLIVA TABONIAG

(Affiant)
Driver’s License#J01-95-018819
Until 2024/06/26

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at Dipolog City.

Doc. No.

Page No.

Book No.

Series of 2021
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ELVIN B. PERMALE of legal age, Filipino, married, a resident of Turno, Dipolog City, Zamboanga del
Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am the father of DELMENRIZA A. PERMALE who was issued a School Identification Card by
Zamboanga del Norte National High School(Main Campus) being one of its students.

That my daughter Delmenriza A. Permale misplaced her identification card sometime year 2020 and
now it is lost;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said identification card.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2021, at
Dipolog City.

ELVIN B. PERMALE
(Affiant)
PhilPost ID#090216
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at Dipolog City.

Doc. No.

Page No.

Book No.

Series of 2021
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ELEONOR RENDON NALZARO, of legal age, Filipino, a resident of Sta.Filomena, Dipolog City,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of a Philippine Passport issued by the Department of Foreign Affairs.

That on June 25,2021, I was looking for my passport at our house in Sta. Filomena, Dipolog City I
found out that it was lost;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said passport.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2021, at
Dipolog City.

ELEONOR RENDON NALZARO

(Affiant)
Philippine Passport #JJ891152

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at Dipolog City.

Doc. No.

Page No.

Book No.

Series of 2021
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, JAIME B. TAMAYO, of legal age, Filipino, single, a resident of Sta.Filomena, Dipolog City, Zamboanga
del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am holder and possessor of Drivers License and an Official Receipt(OR) for the said license.

That sometime May 2021, the Drivers License and OR were lost;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said driver’s license and OR.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2021, at
Dipolog City.

JAIME B. TAMAYO
(Affiant)
Philhealth ID#14-200747321-3

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at Dipolog City.

Doc. No.

Page No.

Book No.

Series of 2021
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, JOSE A. NORIEGA, of legal age, Filipino, married, a resident of Turno, Dipolog City,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose
and state:

That I am a party of civil case involving parcels of land which was filed before Regional Trial
Court Branch 10, Dipolog City with Civil Case No.6435 which was appealed by adverse party
before the Court of Appeals and docketed as CA-GR No.CV NO.03378-MIN and appealed at the
Supreme Court with G.R. No.231154;

That the decision of the abovementioned case is in favor of the undersigned;

That entry of judgment was also issued;

That the copies of the decision and entry of judgment of the said case were released to the
undersigned;

That unfortunately, the original copies of the said decisions and entry of judgment were lost
due to misplacement;

That despite effort to recover the same but it was naught.

Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements
and for the purpose of attesting to the loss of the said documents.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2021,
at Dipolog City.

JOSE A. NORIEGA

(Affiant)

ID#___________________________

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at Dipolog City.
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT

I, DGYRRAH ENOY-SUMAGANG of legal age, Filipino, married to Mike Ammo Sumagang, a resident of
Bandera, Polanco, Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose
and state:

That I am a holder and possessor of an original copy of e-Certificates Authorizing Registration(eCARs) issued
issued by Bureau of Internal Revenue with No. 00004549 and No.00004550 for the taxes.

That the original copy of eCARs issued by the Bureau of Internal Revenue(BIR) was submitted to Register of
Deeds(ROD);

That however upon processing for transfer of title before the Register of Deeds, the original copy was not
anymore in my possession because it was already with ROD;

As such, I am executing this Affidavit to attest to the truth of the foregoing statements and for the purpose of
attesting to the circumstances of the said eCAR and reissuance of the same and claiming the documents at the
Bureau of Internal Revenue anent thereto and/or to process the title before Register of Deeds.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2021, at Dipolog
City.

DGYRRAH ENOY- SUMAGANG

(Affiant)
Postal ID#PRN M83190189140P
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at Dipolog City.

DOC. NO. 1418

PAGE NO.58
BOOK NO.74
SERIES OF 2021
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, EMILIA PULMARAN PACUYAO, of legal age, Filipino, widow, a resident of

Silawe, Polanco, Zamboanga del Norte, after having been duly sworn in
accordance with law, hereby depose and state:

That I am a holder and possessor of Policy Contract No.CM4021013 issued

by Government Service Insurance System(GSIS);

That sometime January 2021, I tried to locate the said policy contract but it
was lost;

That despite efforts, the said document could not be located.Hence, I

considered it as totally lost;

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

foregoing statements and for the purpose of attesting to the loss of the said
GSIS document.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2021, at Dipolog City.

EMILIA PULMARAN PACUYAO

(Affiant)
PRC ID#0230594-Professional Teacher
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at

Dipolog City.

Doc No. _____

Page No. _____
Book No. ____
Series of 2021

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, RIZA MAE P. REDULLA, Filipino, of legal age, single, and a resident of Sta. Filomena,
Dipolog City, Zamboanga del Norte after having been duly sworn in accordance with law, hereby
depose and state:

That I am a holder and possessor of an official receipt issued by MLhuillier for a pawned jewelry of
Earring 2.0g 18K with Receipt No.PTN 0447-2021-00671 in the amount of P4,350.00 pawned on
March 31,2021.

That in June 2021, I found out that my receipt was lost, I tried to locate the receipt but it was really
lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said official receipt of MLhuillier.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2021, at
Dipolog City.

RIZA MAE P. REDULLA

(Affiant)
PRC ID#0027911
Social Worker

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2021

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, NIKKA C. CASTELLANO, of legal age, Filipino, a resident of Olingan,

Dipolog City, after having been duly sworn in accordance with law, hereby
depose and state:

That I am a holder and possessor of a Passbook issued by Katipunan Bank

with Account Number 002-23-1052105;

That in June 2021, while I was trying to look for the said Passbook from
where I kept it, I found out that the Passbook was lost, and could not be
found;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost;

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

foregoing statements and for the purpose of attesting to the loss of the said
Passbook, and request the replacement of the said passbook.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2021, at Dipolog City.

NIKKA C. CASTELLANO
(Affiant)
ID#________________
 With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at

Dipolog City.

Doc No. _____

Page No. _____
Book No. ____
Series of 2021

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT

I, DGYRRAH ENOY-SUMAGANG of legal age, Filipino, married to Mike Ammo Sumagang, a resident of
Bandera, Polanco, Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose
and state:

That I am a holder and possessor of an original copy of e-Certificates Authorizing Registration(eCARs) issued
issued by Bureau of Internal Revenue with No. 00004549 and No.00004550 for the taxes.

That the eCARs issued by the Bureau of Internal Revenue were expired after the reglementary period to submit
for processing of titles;

That however the period to submit and process the said eCARs had passed already;

That the eCAR could no longer be used and processed anymore;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for the
purpose of attesting to the circumstances of the said eCAR and reissuance of the same and claiming the
documents at the Bureau of Internal Revenue anent to the slip.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2021, at Dipolog
City.

DGYRRAH ENOY- SUMAGANG

(Affiant)
Postal ID#PRN M83190189140P
With photo
SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at Dipolog City.

DOC. NO. _____

PAGE NO._____
BOOK NO.____
SERIES OF 2021

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, MARILU CELENA GABALES GALLEMIT, of legal age, Filipino, married, a

resident of Gulayon, Dipolog City, Zamboanga del Norte, after having been
duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of Policy Contract No.CM00004034780

issued by Government Service Insurance System(GSIS);

That I kept the said document at our office at Department of Education-

Zamboanga del Norte;

That sometime June 2021, I tried to locate the said policy contract but it was
lost;

That despite effort, the said document could not be located.Hence, I

considered it as totally lost;

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

foregoing statements and for the purpose of attesting to the loss of the said
GSIS document.
IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of
__________ 2021, at Dipolog City.

MARILU CELENA GABALES GALLEMIT

(Affiant)
UMID ID#CRN-006-0049-1406-0
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at

Dipolog City.

Doc No. _____

Page No. _____
Book No. ____
Series of 2021

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, RONILO MAGSANAY MEGIO, of legal age, Filipino, single/married, a

resident of Poblacion South, Polanco, Zamboanga del Norte, after having
been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of Certificate of Membership/Policy No.CM-

00004024164 for Life insurance issued by Government Service Insurance
System(GSIS) as an employee of Polanco Water District;

That I kept the said document at our office at Highway Obay, Polanco,
Zamboanga del Norte;

That on January 3, 2001, our office at Obay, Polanco was burned down and
my said documents was included to those that were burned to ashes;

Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the
foregoing statements and for the purpose of attesting to the loss of the said
GSIS document.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2021, at Dipolog City.

RONILO MAGSANAY MEGIO

(Affiant)
ID#____________________
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at

Dipolog City.

Doc No. _____

Page No. _____
Book No. ____
Series of 2021

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ROLAND U. AGUSTIN, of legal age, Filipino, married, a resident of

P.Ramon corner P. Gomez Sts., Biasong, Dipolog City, Zamboanga del Norte,
after having been duly sworn in accordance with law, hereby depose and
state:

That I am the owner of the Business Permit of WINGS’S SARI-SARI STORE for
year 2020,which is situated at my said address;

That last April 2021, I made renovations at my store for new business
venture. That I applied for new business permit for the said venture and I
was asked to surrender my business permit so I tried to look for the said
business permit from where I kept it and I found out that the business
permit was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost;

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

foregoing statements and for the purpose of attesting to the loss of the said
business permit.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2021, at Dipolog City.

ROLAND U. AGUSTIN
(Affiant)
UMID ID#CRN-006-0049-1316-8
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at

Dipolog City.

Doc No. _____

Page No. _____
Book No. ____
Series of 2021

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ALONA R. BONAFE, of legal age, Filipino, single, a resident of Tabiliran St., Estaka, Dipolog City,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am holder and possessor of Certificate of Registration(CR) and an Official Receipt(OR) for the
motor vehicle with the following descriptions:

Make:YAMAHA Engine No.:E3R2E2202969

Chassis No.:PA0SE9810J0318058 Plate No.:090105

Color:MATTE BLUE/BLACK Series:MIO I 125 BB36

That on October 25 2019, the U-box of the said motor vehicle was forcibly opened and my CR and OR
were taken and were not returned;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said CR and OR.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2021, at
Dipolog City.

ALONA R. BONAFE
(Affiant)
Driver’s License#J01-18-002406
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at Dipolog City.

Doc. No.

Page No.

Book No.

Series of 2021

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS
I, EDILLO C. DIVINAGRACIA, of legal age, Filipino, single/married, a resident of Anastacio, Polanco,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am holder and possessor of Drivers License and an Official Receipt(OR) for the said license.

That sometime May 2021, the Drivers License and OR were lost;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said driver’s license and OR.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2021, at
Dipolog City.

EDILLO C. DIVINAGRACIA
(Affiant)
Driver’s License#N0117044369

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at Dipolog City.

Doc. No.

Page No.

Book No.

Series of 2021
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ANALISA B. NADELA, of legal age, Filipino, married, a resident of Lapu-lapu St., Estaka, Dipolog City,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of my Development Bank of the Philippines(DBP) Automated Teller
Machine(ATM) card for my salaries/benefits as Department of Educaction(DepEd) employee, DepEd
ID, Pag-ibig MID Card, GSIS UMID card, and PRC ID.

That on June 13, 2021, my wallet containing those cards was lost;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said DBP ATM card, DepEd ID, Pag-ibig MID card, GSIS UMID
card and PRC ID.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2021, at
Dipolog City.

ANALISA B. NADELA
(Affiant)
CTC #CCI2-1914727975
Issued at Estaka, Dipolog City
Issued on June 14, 2021

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at Dipolog City.

Doc. No.
Page No.

Book No.

Series of 2021

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, NELSON C. GONZALES, of legal age, Filipino, married, a resident of Dicayo, Katipunan, Zamboanga
del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of an Official Receipt(OR) and Certificate of Registration(CR) for
motor vehicle with Plate No. 7894 JH, Chassis No. XRM16026496.

That sometime May, 2021, I checked the OR and CR of my motor vehicle with Plate No.7894 JH at the
motorcycle seat box(U-Box) and I found out that they were lost;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said OR and CR of motor vehicle.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2021, at
Dipolog City.

NELSON C. GONZALES
(Affiant)
Driver’s License#J01-01-037404
SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at Dipolog City.

Doc. No.

Page No.

Book No.

Series of 2021

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, JOSELIER S. AJO, of legal age, Filipino, single, a resident of West Estaka, Dipolog City, Zamboanga del
Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of an Official Receipt for a purchase of Devant Flatscreen Smart
Television with amount of P33,740.00 issued by Solidmark-Dipolog City Branch on November 16,
2019.

That I owned the said television;

That sometime May 2021, while I was trying to look for my said official receipt from my file folder,
then I found out that official receipt was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said official receipt.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2021, at
Dipolog City.

JOSELIER S. AJO
 (Affiant)
Drivers License#J01-13-003755
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2021

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, RODOLFO C. DALMAN of legal age, Filipino, married, a resident of Gen Luna St. Estaka, Dipolog City
after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of an original copy of e-Certificates Authorizing Registration(eCARs)

issued issued by Bureau of Internal Revenue with No. eCR201800001977 and eCR2018000019778 for
the estate taxes.

That last week of July 2020, while I was trying to look for my said eCARs from my file folder, then I
found out that the eCARs were lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said eCAR and reissuance of the same and claiming the
documents at the Bureau of Internal Revenue anent to the slip.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2021, at
Dipolog City.
 RODOLFO C. DALMAN
(Affiant)
TIN#949-091-870
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at Dipolog City.

DOC. NO. _____

PAGE NO._____
BOOK NO.____
SERIES OF 2021

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, PELIGRENA CAMATURA of legal age, Filipino, single/married/widow, a resident of Relocation Site,

Olingan, Dipolog City, Zamboanga del Norte after having been duly sworn in accordance with law,
hereby depose and state:

That I am a holder and possessor of a Senior Citizen’s ID issued by Office of the Senior Citizen’s Affairs.

That sometime last week, while I was riding a tricycle in Dipolog City, my bag containing the said
identification card was lost;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.
As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said Senior Citizen’s ID issued by OSCA.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2021, at
Dipolog City.

PELIGRENA CAMATURA
(Affiant)
ID#_______________________

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at Dipolog City.

Doc. No.

Page No.

Book No.

Series of 2021

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, JESIBEL A. CLERIGO, of legal age, Filipino, single, a resident of Sinai, Sergio Osmena, Zamboanga del
Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am the representative of a holder and possessor of Certificate of Registration and official
receipt with No. 1594026070 issued by Land Transportation Office for motor vehicle with Certificate
of Registration No.279491030.
That sometime May 2021, while I was trying to look for my said certificate of registration and official
receipt from my file folder, then I found out that certificate of registration and official receipt were
lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said certificate of registration and official receipt.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2021, at
Dipolog City.

JESIBEL A. CLERIGO
(Affiant)
Drivers License#J01-20-003254
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2021

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, JAY NHEL D. BROÑOLA, of legal age, Filipino, single, a resident of Barra, Dipolog City, Zamboanga del
Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am representative of CHERRYMAE B. JAU, holder and possessor of Drivers License and an
Official Receipt(OR) for the said license.
That on March 27, 2021, the Drivers License and OR were lost;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said driver’s license and OR.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2021, at
Dipolog City.

JAY NHEL D. BROÑOLA

(Affiant)
Driver’s License#J01-19-005295

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at Dipolog City.

Doc. No.

Page No.

Book No.

Series of 2021

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS
I, ANNELYN S. SORIANO, of legal age, married , Filipino, a resident of Sicayab, Dipolog City
after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder/possessor of Certificate of Full Payment issued by Caritas Health Shield

Incorporated for my insurance policy with Policy No. E510-1308632 in the amount of
P214,160.00 covering the the period of October 29, 2010-October 29, 2020;

That sometime November, 2020, after I received the certificate of full payment I kept it in my
file folder and later I tried to locate the said certificate but I could not find it;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements
and for the purpose of attesting to the loss of the said certificate of full payment.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ____ day of __________
2021, at Dipolog City.

ANNELYN S. SORIANO
(Affiant)
UMID ID#CRN-006-0052-5159-9
With photo

SUBSCRIBED AND SWORN to before me this ___ day of ________ 2021, at Dipolog City.

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS
I, ANTHONY G. SORIANO, of legal age, married , Filipino, a resident of Sicayab, Dipolog City
after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder/possessor of Certificate of Full Payment issued by Caritas Health Shield

Incorporated for my insurance policy with Policy No. E510-1310775 in the amount of
P186,310.00 covering the the period of November 2, 2010-November 2, 2020;

That sometime November, 2020, after I received the certificate of full payment I kept it in my
file folder and later I tried to locate the said certificate but I could not find it;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements
and for the purpose of attesting to the loss of the said certificate of full payment.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ____ day of __________
2021, at Dipolog City.

ANTHONY G. SORIANO
(Affiant)
OSCA ID#11845
Issued at: Dipolog City

SUBSCRIBED AND SWORN to before me this ___ day of ________ 2021, at Dipolog City.

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x
 AFFIDAVIT OF CONSENT ON ROAD RIGHT OF WAY

I, GERMAN P. CA-AY, of legal age, Filipino, single, a resident of Lingasad, Polanco, Zamboanga del
Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am the owner of parcel of land known as Lot 6662-B-2, Psd-09-082010 situated at Larayan,
Dapitan City.

That I am the brother Jeffrey P.Ca-ay who is the owner of Lot 6662-B-4,Psd-09-082010;

That my brother Jeffrey P. Ca-ay has processed the subdivision of his land and he has provided a road
right known as Lot 6662-B-4-I with an area of 107 square meters;

That I, as owner of the adjacent Lot 6662-B-2, Psd-09-082010, hereby give my consent that I would
give an area of 108 square meters as provision of road right and that road right is adjacent to
proposed Lot 6662-B-4-I;

That the road right provided is given and unconditionally set to my brother Jeffrey P. Ca-ay for the
approval of his proposed subdivision plan on Lot 6662-B-4, Psd-09-082010;

That I execute this affidavit of justification to attest the foregoing statement;

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2021, at
Dipolog City.

GERMAN P. CA-AY
(Affiant)
TIN# 496-058-340

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at Dipolog City.
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ERIC O. SAGUIN, of legal age, Filipino, married, a resident of Banonong, Dapitan City,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose
and state:

That I am a holder and possessor of a Driver’s License ID with No.J01-04-000677 issued by the
Land Transportation Office.

That on May 27, 2021, my LTO Driver’s License was lost after traveled to Dipolog City;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements
and for the purpose of attesting to the loss of the said Driver’s License ID.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2021,
at Dipolog City.

ERIC O. SAGUIN
(Affiant)
DL ID#J01-04-000677

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at Dipolog City.

Doc. No.

Page No.

Book No.

Series of 2021
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, JOY S. CABANLIT, of legal age, Filipino, married to Samuel Gandola(now marriage declared as
nulled), a resident of Prk Bayanihan, Sta.Filomena, Dipolog City, Zamboanga del Norte after having
been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of a Philippine Passport issued by the Department of Foreign Affairs.

That on November 25,2020, I was looking for my passport after we relocated to our house in Sta.
Filomena, Dipolog City I found out that it was lost;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said passport.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2021, at
Dipolog City.

JOY S. CABANLIT
(Affiant)
Philippine Passport #EC1136573
SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at Dipolog City.

Doc. No.

Page No.

Book No.

Series of 2021

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, JAMES CAYLAN of legal age, Filipino, single/married, a resident of Sta.Filomena, Dipolog City after
having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of an original copy of receipts issued issued by Bureau of Internal
Revenue for the estate taxes and documentary stamp taxes of Zosimo Caylan and Eustaquia J. Caylan,
my parents.

That last week of April 2021, while I was trying to look for my said receipts from my file folder, then I
found out that receipts were lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said receipts and reissuance of receipts of the same.
IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2021, at
Dipolog City.

JAMES CAYLAN
(Affiant)
OSCA ID#113311-Dipolog City
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at Dipolog City.

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, CONCORDIO B. BAEL, of legal age, Filipino, single/married, a resident of Dipolog City, Zamboanga del
Norte after having been duly sworn in accordance with law, hereby depose and state:

That, as geodetic enginner, I am a holder and possessor of a sepia copy and corresponding Technical
Descriptions of Approved Subdivision Plan PSD-09-055719 for parcel of land situated at Olingan,
Dipolog City.

That sometime third week of April 2021, while I was checking my file folder containing the said
document so that I could process the land and its revision, I found out that the technical description
documents were lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.
As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said sepia copy and technical descriptions documents and
request for replacement of the same.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2021, at
Dipolog City.

CONCORDIO B. BAEL
(Affiant)
ID#______________

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at Dipolog City.

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, JENELYN Y. TACUJAN, of legal age, Filipino, widow, resident of Galas, Dipolog City after having been
duly sworn in accordance with law, hereby depose and state:

That I am the widow of Renewil Tacujan, holder and possessor of Certificate of Registration(CR) for motor
vehicle with following details:

MAKE: HONDA
MV File No.0908-00003313609
Engine No.XRM16E088412
Chassis No.XRM16088412
Series:CFT125MA
That on April 27, 2021, the CR of motor vehicle was lost;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for the
purpose of attesting to the loss of the said CR of motor vehicle.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2021, at Dipolog
City.

JENELYN Y. TACUJAN
(Affiant)
Philhealth ID#14-025246312-3

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at Dipolog City.

Doc. No.

Page No.

Book No.

Series of 2021

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, JUVENAL Y. MONTEROS, of legal age, Filipino, married, a resident of Zone

1 Canitoan, Cagayan de Oro, Misamis Oriental, after having been duly sworn
in accordance with law, hereby depose and state:
That I am a holder and possessor of the Purchase Order with reference
number CSW#174088 issued by LP City Central Supermarket, Dipolog City
for delivery of several orders of LP City Central-Supermarket;

That I am an agent of YSU Marketing Corp;

That on May 12, 2021, while I tried to deliver the goods to LP City Central –
Supermarket, I found out that the Original Copy of the said Purchase Order
was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost;

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

foregoing statements and for the purpose of attesting to the loss of the said
Purchase Order CSW#174088.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2021, at Dipolog City.

JUVENAL Y. MONTEROS
(Affiant)
Driver’s License#K02-96-067090
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at

Dipolog City.

Doc No. _____

Page No. _____
Book No. ____
Series of 2021

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x
 AFFIDAVIT OF LOSS

I, JOHN M. ALOSADA, of legal age, Filipino, single, a resident of Malusay,

Guihulngan City, Negros Oriental, after having been duly sworn in
accordance with law, hereby depose and state:

That I am a holder and possessor of a Passbook issued by Philippine Army

Finance Center Producers Integrated Cooperative with number 182228;

That in January 2021, while I was trying to look for the said Passbook from
where I kept it, I found out that the Passbook was lost, and could not be
found;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost;

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

foregoing statements and for the purpose of attesting to the loss of the said
Passbook, and request the replacement of the said passbook.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2021, at Dipolog City.

JOHN M. ALOSADA
(Affiant)
AFP ID#A21-E-267378
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at

Dipolog City.

Doc No. _____

Page No. _____
Book No. ____
Series of 2021
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ROMEO M. SERANA, of legal age, Filipino, married, a resident of

Barangay Mauswagon, La Libertad, Zamboanga del Norte, after having been
duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of Additional Policy Contracts with

No.2001040804 for beneficiary Rudking Serana and with No. 2001050194
for beneficiary Cindy Joy Serana, issued by Armed Forces and Police Mutual
Benefits Association, Inc.(AFPMBAI);

That in April, 2021, while I was trying to look for the said Additional Policy
Contracts from my file where I kept it, I found out that the certification was
lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost;

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

foregoing statements and for the purpose of attesting to the loss of the said
Additional Policy Contracts issued by AFPMBAI.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2021, at Dipolog City.

ROMEO M. SERANA
(Affiant)
PNP ID No.18D130211
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at

Dipolog City.
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ROMEO M. SERANA, of legal age, Filipino, married, a resident of

Barangay Mauswagon, La Libertad, Zamboanga del Norte, after having been
duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of a Basic Policy, issued by Armed Forces

and Police Mutual Benefits Association, Inc.(AFPMBAI);

That in April, 2021, while I was trying to look for the said Basic Policy
Contract from my file where I kept it, I found out that the certification was
lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost;

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

foregoing statements and for the purpose of attesting to the loss of the said
Basic Policy Contract issued by AFPMBAI.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2021, at Dipolog City.

ROMEO M. SERANA
(Affiant)
PNP ID No.18D130211
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at

Dipolog City.
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ROMEO M. SERANA, of legal age, Filipino, married, a resident of

Barangay Mauswagon, La Libertad, Zamboanga del Norte, after having been
duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of a Basic Policy, as member of Armed

Forces of the Philippines, issued by Armed Forces and Police Mutual Benefits
Association, Inc.(AFPMBAI);

That in April, 2021, while I was trying to look for the said Basic Policy
Contract from my file where I kept it, I found out that the certification was
lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost;

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

foregoing statements and for the purpose of attesting to the loss of the said
Basic Policy Contract issued by AFPMBAI.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2021, at Dipolog City.

ROMEO M. SERANA
(Affiant)
PNP ID No.18D130211
With Photo
SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at
Dipolog City.

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, WINSTON E. SAGAPSAPAN, of legal age, Filipino, single/married, a resident of Gulayon, Dipolog City,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am representative of holder and possessor of Certificate of Registration(CR) for motor vehicle
with Plate No. 4425JR under the name of Aldren Rey Q. Sagan.

That on April 27, 2021, the CR of motor vehicle with Plate No.4425JR was lost;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said CR of motor vehicle.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2021, at
Dipolog City.

WINSTON E. SAGAPSAPAN
(Affiant)
Driver’s License#J01-11-001541

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at Dipolog City.
Doc. No.

Page No.

Book No.

Series of 2021

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, WINSTON E. SAGAPSAPAN, of legal age, Filipino, single/married, a resident of Gulayon, Dipolog City,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:
That I am representative of holder and possessor of an Official Receipt and Certificate of
Registration(OR/CR) for motor vehicle with Plate No. JA 24815 under the name of Kerrmark P. Sagan
and OR No.1813747165.

That on March 27, 2021, the OR/CR of motor vehicle with Plate No.JA 24815 was lost;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said OR/CR of motor vehicle.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2021, at
Dipolog City.

WINSTON E. SAGAPSAPAN
(Affiant)
Driver’s License#J01-11-001541

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at Dipolog City.

Doc. No.

Page No.

Book No.

Series of 2021

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, SANNY O. BURLAYAN, of legal age, Filipino, single, a resident of Martinez St., Central Barangay,
Dipolog City, Zamboanga del Norte after having been duly sworn in accordance with law, hereby
depose and state:
That I am a holder and possessor of a Cellular phone Dual sim with Talk’n Text simcard Number
09500233134 and with another TM simcard Number 09977242094 .

That on May 1, 2021, I discovered that my said cellular phone was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said cellular phone with sim card and thereafter requesting
replacement of TM simcard number 09977242094 and Talk’n Text number 09500233134.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2020, at
Dipolog City.

SANNY O. BURLAYAN
(Affiant)
Voters ID#7202-0003A-G0882SOB10000

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2020, at Dipolog City.

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS
I, LELANIE MACO CANDARE, of legal age, Filipino, married, a resident of
Tabon, Jose Dalman, Zamboanga del Norte, after having been duly sworn in
accordance with law, hereby depose and state:

That I am a holder and possessor of a 1 st Valley Bank Passbook with number

126056008123/26;

That last week, while I was trying to look for the said Passbook from where I
kept it, I found out that the Passbook was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost;

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

foregoing statements and for the purpose of attesting to the loss of the said
Passbook, and request the replacement of the said passbook.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2021, at Dipolog City.

LELANIE MACO CANDARE

(Affiant)
TIN#495-347-308
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at

Dipolog City.

Doc No. _____

Page No. _____
Book No. ____
Series of 2021
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, RAINGER M. SALVO, of legal age, Filipino, married to Crystal A. Salvo, a resident of San Antonio,
Manukan, Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose
and state:

That I am the holder and possessor of approved survey plan and technical description of Lot No.404-
C-3 PSD-09-083206 under parcel of land covered by TCT No.T-14154 with approved survey plan PSD-
09-083206.

That I kept the Approved Survey and it attachements but Technical Descriptions for Lot No.404-C-3,
Psd-09-083206 of the said parcel of land was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said Technical Descriptions of Lot No.404-C-3 and for
reproduction of the same.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2021, at
Dipolog City.

RAINGER M. SALVO
(Affiant)
PNP ID#173090626

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2021
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, VIOLETA VELASCO LOGRONIO, of legal age, Filipino, married, resident of Miputak, Dipolog City,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am the attorney-n-fact of owner of a parcel of land, more particularly described as follows:

A parcel of land known as Lot 862-I-2-B, Psd-09-7202-018677, covered by Transfer Certificate of Title No. T-
9531 located at Miputak, Dipolog City, Zamboanga del Norte with an area of 320 square meters.

That my mother Bonifacia Solon is the owner of the said parcel of land who misplaced the owner’s copy of the
title and could not locate it anymore;

That despite effort to recover the same but it was naught.

That I considered it as totally lost.

That I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for the purpose
of attesting to the loss of the said Transfer Certificate of Title No.T-9531.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2021, at Dipolog
City.

VIOLETA VELASCO LOGRONIO

(Affiant)

ID#____________________

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at Dipolog City.
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, EDGAR Q. PAGE, of legal age, Filipino, married, a resident of Polo,

Dapitan City, Zamboanga del Norte, after having been duly sworn in
accordance with law, hereby depose and state:

That I am a holder and possessor of a Philippine National Bank(PNB)

Passbook with number 3466-3710-0011 under the names of Edgar Q. Page
and Victoria E. Page, jointly;

That last week, while I was trying to look for the said Passbook from where I
kept it, I found out that the Passbook was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost;

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

foregoing statements and for the purpose of attesting to the loss of the said
Passbook, and request the replacement of the said passbook.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2021, at Dipolog City.

EDGAR Q. PAGE
(Affiant)
Driver’s License#J01-93-015526
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at

Dipolog City.

Doc No. _____

Page No. _____
Book No. ____
Series of 2021
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, VICENTE ARAGON PAGHUBASAN, SR., of legal age, Filipino, single/married/widow/widower, a

resident of Betlehem, Polanco, Zamboanga del Norte after having been duly sworn in accordance
with law, hereby depose and state:

That I am a holder and possessor of a Driver’s License Identification Card(ID) issued by the Land
Tranportation Office, SSS ID issued by Social Security System, Voter’s ID issued by COMELEC,
Philhealth ID issued by Philippine Health Insurance Corp., Senior Citizen’s ID issued by OSCA.

That on May 3, 2021 at about 1:00pm, my tactical bag containing those identification cards was
misplaced and was lost;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said Driver’s License Identification Card(ID) issued by the
Land Tranportation Office, SSS ID issued by Social Security System, Voter’s ID issued by COMELEC,
Philhealth ID issued by Philippine Health Insurance Corp., Senior Citizen’s ID issued by OSCA.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2021, at
Dipolog City.

VICENTE ARAGON PAGHUBASAN,SR.

(Affiant)
DL#J0119008552

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at Dipolog City.

Doc. No.

Page No.
Book No.

Series of 2021

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, JHOAN ALIMOREN MONTILLANO, of legal age, Filipino, single, a resident of Siparok, Jose Dalman,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of a Philippine Passport issued by the Department of Foreign Affairs.

That sometime December 2015, there was a flood in my residence in Manila at that time and my
passport was taken by flood and was lost;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said passport.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2021, at
Dipolog City.

JHOAN ALIMOREN MONTILLANO

(Affiant)
Philhealth ID#15-050002345-9

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at Dipolog City.

Doc. No.
Page No.

Book No.

Series of 2021

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ROWENA B. DIZON, of legal age, Filipino, widow, a resident of

Sta.Filomena, Dipolog City, Zamboanga del Norte, after having been duly
sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of a 1 st Valley Bank Passbook with number

11551002897 under the name of my late spouse Gelbert M. Dizon;

That last week, while I was trying to look for the said Passbook from where I
kept it, I found out that the Passbook was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost;

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

foregoing statements and for the purpose of attesting to the loss of the said
Passbook, and request the replacement of the said passbook.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2021, at Dipolog City.

ROWENA B. DIZON
(Affiant)
 ID#__________________
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at

Dipolog City.

Doc No. _____

Page No. _____
Book No. ____
Series of 2021

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, JHORLIE TORRES SAING, of legal age, Filipino, married, a resident of Punta, Liloy, Zamboanga del
Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of a Driver’s License ID issued by the Land Transportation Office.

That on April 27, 2021, my LTO Driver’s License was stolen together with my cellular phone at Ipil,
Zamboanga Sibugay and I reported the incident at the Ipil Police Station;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said Driver’s License ID.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2021, at
Dipolog City.

JHORLIE TORRES SAING

(Affiant)
ID#__________
SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at Dipolog City.

Doc. No.

Page No.

Book No.

Series of 2021

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, PETER E. BAGALANON, of legal age, Filipino, married, a resident of

Barangay Aseniero, Dapitan City, after having been duly sworn in
accordance with law, hereby depose and state:

That I am a holder and possessor of a Basic Policy, as member of Armed

Forces of the Philippines, issued by Armed Forces and Police Mutual Benefits
Association, Inc.(AFPMBAI);
That in APril, 2021, while I was trying to look for the said Basic Policy
Contract from my file where I kept it, I found out that the certification was
lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost;

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

foregoing statements and for the purpose of attesting to the loss of the said
Basic Policy Contract issued by AFPMBAI.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2021, at Dipolog City.

PETER E. BAGALANON
(Affiant)
AFP ID#A19-E-221331
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at

Dipolog City.

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, EDUARDO S. CEDEÑO, of legal age, Filipino, single, resident of Lapu-lapu, Pinan, Zamboanga del Norte
after having been duly sworn in accordance with law, hereby depose and state:
That I am the co-owner of a parcel of land, more particularly described as follows:

A parcel of land known as Lot 3, CCS-09-08-000027-D(Identical to Lot 6451,Pls-100), covered by Original

Certificate of Title No. (P-24139)1247 located at Napuyan, Dapitan City, Zamboanga del Norte with an area of
20,008 square meters.

That the said title was registered under the name of my parents Sergia S. Cedeño, married to Zacarias Cedeño,
who were already dead and they had the possession of the owner’s copy of the said title;

That after their death, the owner’s copy was lost also and I tried to locate the copy of the title;

That despite effort to recover the same but it was naught.

That I considered it as totally lost.

That I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for the purpose
of attesting to the loss of the said Original Certificate of Title No.(P-24139)1247.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2021, at Dipolog
City.

EDUARDO S. CEDEÑO

(Affiant)

LTO Driver’s License#J01-18-001739

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at Dipolog City.

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x
 AFFIDAVIT OF LOSS

I, RONNEL A. MANDANTES, of legal age, Filipino, single, a resident of Turno, Dipolog City, Zamboanga
del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of a Driver’s License ID issued by the Land Transportation Office.

That in March, 2021, my LTO Driver’s License inside my pocket was lost;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said Driver’s License ID.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2021, at
Dipolog City.

RONNEL A. MANDANTES
(Affiant)
UMID ID#CRN-0111-5572104-2

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at Dipolog City.

Doc. No.

Page No.

Book No.

Series of 2021

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS
I, VON RENEL T. DAYRIT, of legal age, Filipino, single, a resident of 408
Prurok Maalagaron, Turno, Dipolog City, Zamboanga del Norte, after having
been duly sworn in accordance with law, hereby depose and state:

That I am the keeper of the Business Permit of Manila Bootery owned by

Bernardo Tiglao, situated at Estaka, Dipolog City;

That last week, while I was trying to look for the said business permit from
where I kept it, I found out that the business permit was lost, and could not
be found;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost;

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

foregoing statements and for the purpose of attesting to the loss of the said
business permit.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2021, at Dipolog City.

VON RENEL T. DAYRIT

(Affiant)
UMID ID#CRN-0111-5722528-7
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at

Dipolog City.

Doc No. _____

Page No. _____
Book No. ____
Series of 2021
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, NOLI C. MALIGRO, of legal age, Filipino, widower, a resident of Liyang, Dapitan City, Zamboanga del
Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of a Driver’s License ID issued by the Land Transportation Office, SSS
ID card issued by SSS, and Official Receipt and Certificate of Registration for motor vehicle with Plate
No. 3137 JP.

That on March 27, 2021, my wallet containing the said SSS ID, LTO Driver’s License and OR/CR of
motor vehicle with Plate No.3137 JP was lost;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said Driver’s License ID, SSS ID and OR/CR of motor vehicle.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2021, at
Dipolog City.

NOLI C. MALIGRO
(Affiant)
ID#_____________________

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at Dipolog City.

Doc. No.

Page No.

Book No.

Series of 2021
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ALEXIA MAE M. GALEOS, of legal age, Filipino, single, a resident of Blk 13, Lot 13, Victoria Country
Homes, Obay,Polanco, Zamboanga del Norte after having been duly sworn in accordance with law,
hereby depose and state:

That I am a holder and possessor of a Philippine Passport with number EC5044395 issued by the
Department of Foreign Affairs.

That sometime November 2020, I was trying to locate my passport but it was lost;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said passport.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2021, at
Dipolog City.

ALEXIA MAE M. GALEOS

(Affiant)
Phil. Postal ID#PRN M83210008410P

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at Dipolog City.

Doc. No.

Page No.

Book No.

Series of 2021
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT

We, SARA E. OCUPE, of legal age, Filipino, a resident of Obay, Polanco,

Zamboanga del Norte, and ROLAND OCUPE, of legal age, Filipino, a resident
of Polanco,Zamboanga del Norte, after having been duly sworn in
accordance with law, hereby depose and state:

That I, Sara E. Ocupe, am the heir of Leonardo Ocupe,Jr, and I, Roland

Ocupe are the co-owners of parcel of land, more particularly described as
follows:

A parcel of land covered by Transfer Certificate of Title No. T-44703 situated

at Isis, Polanco,Zamboanga del Norte

That a subdivision survey was prepared by Engr. Edward Ponteros on July 2,

2020;

That the said survey was made for application of subdivision project;

That we here attest and certify that an alley or road right of way is provided
for a wide of four(4) meter going to Lot 3781-D;

That the said road right of way shall be used as service road for all, without
additional cost;

That the said road right of way is represented by dotted line traversing
along Lot 3781-G also in the said plan;

That we are executing this Affidavit to attest to the truth of the foregoing
statements.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2021, at Dipolog City.
 SARA E. OCUPE
(Affiant)
UMID#CRN-006-0040-3746-8
With Photo

ROLAND OCUPE
(Affiant)
ID#___________________

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at

Dipolog City.

Doc No. _____

Page No. _____
Book No. ____
Series of 2021

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, AXZEL ROSE S. DANIEL, of legal age, Filipino, single, a resident of Galas,

Dipolog City, Zamboanga del Norte, after having been duly sworn in
accordance with law, hereby depose and state:

That I am the keeper of the Business Plate of Rodel Trucking Service owned
by Bonifacio O. Delmo which has Business Permit No.001405, situated at
South Curvada, Galas, Dipolog City;

That last week, while I was trying to look for the said business plate from
where I kept it, I found out that the business plate was lost, and could not
be found;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost;
As such, I am executing this Affidavit of Loss to attest to the truth of the
foregoing statements and for the purpose of attesting to the loss of the said
business plate.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2021, at Dipolog City.

AXZEL ROSE S. DANIEL

(Affiant)
Phihealth ID#14-252635729-8
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at

Dipolog City.

Doc No. _____

Page No. _____
Book No. ____
Series of 2021

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, SAMMY T. SUMATRA, of legal age, Filipino, married, a resident of Obay,

Polanco, Zamboanga del Norte, after having been duly sworn in accordance
with law, hereby depose and state:

That I am a holder and possessor of contract agreement between Evergood

Machineries, Equipment and Supplies Corp. and DL Enterprises for two(2)
oxygen tanks with ref.numbers EG1941 and EG 303;
That the contract was being filed by the office clerk of DL Enterprises
however the said clerk resigned and did not turn-over the files of DL
Enterprises, thus it is lost;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost;

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

foregoing statements and for the purpose of attesting to the loss of the said
contract agreement.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2021, at Dipolog City.

SAMMY T. SUMATRA
(Affiant)
DL#J01-20-002107
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at

Dipolog City.

Doc No. _____

Page No. _____
Book No. ____
Series of 2021

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS
I, MARIANO C. CANDELARIA,JR, of legal age, Filipino, widower, a resident of
Gutalac, Zamboanga del Norte, after having been duly sworn in accordance
with law, hereby depose and state:

That I am a holder and possessor of a Development Bank of the

Philippines(DBP) Passbook with number 0-05262-815-5 under the name of
Madaja Builders & Construction Supply(Madaja) issued by DBP-Dipolog City
Branch;

That I am President of Madaja;

That last week, while I was trying to look for the said DBP Passbook from
where I kept it, I found out that the DBP Passbook was lost, and could not be
found;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost;

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

foregoing statements and for the purpose of attesting to the loss of the said
DBP Passbook, and request the replacement of the said passbook.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2021, at Dipolog City.

MARIANO C. CANDELARIA,JR
(Affiant)
ID#__________________
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at

Dipolog City.

Doc No. _____

Page No. _____
Book No. ____
Series of 2021
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT ON CONFIRMATION OF SALE

We, PERPETUA ENJAMBRE VDA. DE BARTE, widow; THELMA BARTE-OCUPE, married to

Christopher Ocupe; JOSEPHINE BARTE-TABUDLONG, married to Estercasio Tabudlong,Jr;
ARSENIO BARTE,JR, single, and AILEEN BARTE-BARBA,single; all of legal age, all Filipinos,
and all residents of Anastacio, Polanco, Zamboanga del Norte after having been duly
sworn in accordance with law, hereby depose and state:

That we are parties to the Deed of Extrajudicial Partition of Estate with Waiver of Rights;
Deed of Donation Inter-vivos; and Simultanenous Sale of a portion of Estate notarized
before Aileen A. Zorrilla-Febiar with Doc No.1391, Page No.86, Book No.6, Series of 2003;

That we are the only surviving parties who executed the said document;

That the said documents two(2) parcels of land;

That in the deed of sale part under Item XIII, we hereby confirm that the sale of 20,288
square meters in favor of Vicente Tangcalagan and Elnora Francisco consist of the
following area details:

An area of 10,294 square meters is taken from portion of Transfer Certificate of

Title No.T-12053 and an area of 9,994 square meters is taken from portion of Transfer
Certificate of Title No.T-17250.
That in the deed of sale part under Item XIV, we hereby confirm that the sale of 6,763
square meters in favor of Benedicto Catahay and Dolores Gonzales consist of the
following area details:

An area of 3,785 square meters is taken from portion of Transfer Certificate of Title
No.T-12053 and an area of 2,978 square meters is taken from portion of Transfer
Certificate of Title No.T-17250.

That we are executing this Affidavit to attest the foregoing statements.

IN WITNESS WHEREOF, we have hereunto affixed our signature this ___ day of __________
2021, at Dipolog City.

PERPETUA ENJAMBRE VDA. DE BARTE THELMA BARTE-OCUPE

(Affiant) (Affiant)
ID#________________________________ ID#________________________

JOSEPHINE BARTE-TABUDLONG ARSENIO BARTE,JR

(Affiant) (Affiant)
ID#________________________________ ID#________________________

AILEEN BARTE-BARBA
(Affiant)
ID#_____________________

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2021

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ROANNE MARIE C. REDILLAS, of legal age, Filipino, single, a resident of Sta. Isabel, Dipolog City,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:
That I am the sister of Hanna Lilac C. Redillas who graduated the baccalaureate course of Bacherlor of
Science in Sociology at Silliman University, Dumaguete City.

That my sister was issued a copy of her Transcript of Records(ToR), Certificate of Honorable Dismissal,
and Certificate of Good Moral Character from the said university on February 3, 2017. That she later
went to United States of America.

That I became safekeeper and possessor of the Transcript of Records(ToR), Certificate of Honorable
Dismissal, and Certificate of Good Moral Character of my sister HANNA LILAC C. REDILLAS, who now
carries the last name of BECERRA after she married to William Albert Becerra, issued by Silliman
University, Dumaguete City.

That in March 2021, my sister Hanna Lilac C. Redillas-Becerra called me to ask for her documents but I
forgot the place where I kept it and I could not retrieve it anymore.

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said documents and thereafter requesting replacement
thereon.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2021, at
Dipolog City.

ROANNE MARIE C. REDILLAS

(Affiant)
ID#________________________________

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2021
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, HEIDI D. SALAC, of legal age, Filipino, married, a resident of Lapu-lapu

St., Estaka, Dipolog City, Zamboanga del Norte, after having been duly
sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of an ATM card issued by BDO;

That last week, while I was trying to look for the said BDO ATM card from
where I kept it, I found out that the ATM card was lost, and could not be
found;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost;

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

foregoing statements and for the purpose of attesting to the loss of the said
ATM card, and request the replacement of the said card.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2021, at Dipolog City.

HEIDI D. SALAC
(Affiant)
UMID ID#CRN-006-0041-0753-4
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at

Dipolog City.
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ROGER C. LAURQUE, of legal age, Filipino, married, a resident of Poblacion North, Polanco,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am the holder and possessor of approved survey plan and technical descriptions of lot 131
covered by OCT No. P-5860 which is known as PSD-09-023792.

That I kept the Approved Survey and it attachement but Technical Descriptions of the said parcel of
land was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said Technical Descriptions of 2 sub- Lots and for
reproduction of the same.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2021, at
Dipolog City.

ROGER C. LAURQUE
(Affiant)
ID#_________________

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2021
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, CECILIA O. TALITUD, of legal age, Filipino, single, a resident of New Tambo, Katipunan, Zamboanga
del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of a Tax Identification Number(TIN) ID with number 411-651-749
issued by Bureau of Internal Revenue.

That on March 21, 2021, I discovered that my TIN ID was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said TIN ID and thereafter requesting replacement thereon.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2021, at
Dipolog City.

CECILIA O. TALITUD
(Affiant)
Philhealth ID#19-026601270-9

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2021
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, LUCITA T. GEBONEss, of legal age, Filipino, married/widow, a resident of Lingasad, Polanco,

Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of a Passbook issued by Rural Bank of Rizal, Polanco, Zamboanga del
Norte Branch .

That on March 21, 2021, I discovered that the passbook was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said passbook and thereafter requesting replacement
thereon.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2021, at
Dipolog City.

LUCITA T. GEBONE
(Affiant)
OSCA ID#18-02177-Polanco,ZN

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2021
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, NELITA D. NASALA, of legal age, Filipino, single, resident of Dicayas,

Dipolog City after having been duly sworn in accordance with law, hereby
depose and state:

That I am a holder and possessor of Certificate of Registration(CR) for

motor vehicle issued by LTO with Plate Number KH 3514, CR No.20602416
and Official Receipt(OR) No. 620166433.

That on February 1, 2021, I discovered that folder containing CR and OR of

my vehicle was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost;

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

foregoing statements and for the purpose of attesting to the loss of the said
CR of my vehicle with plate number KH 3514 and OR No. 620166433.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2021, at Dipolog City.

NELITA D. NASALA
(Affiant)
UMID ID#CRN-006-0024-7380-4
SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021 at
Dipolog City.

Doc.No.

Page No.

Book No.

Series of 2021

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, AIREEN E. PAGLALUNAN, of legal age, Filipino, single, a resident of Hilltop, Dapitan City,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose
and state:

That I am a Teacher II employed by Ilaya National High School, Department of Education.

That sometime in year 2015 I secured my Permit to Study issued by Office of Schools Division
Superintendent and I eventually studied my Masteral Degree at Saint Vincent’s College. Then
in July 2020 I checked file folder of documents where I always kept all documents like
employment records including the said Permit to Study covering semesters of 2015-2017, but I
found out that my Permit to Study was lost, and could not be found;

That despite effort to recover the same but it was naught.

Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements
and for the purpose of attesting to the loss of the said Permit to Study.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2021,
at Dipolog City.
 AIREEN E. PAGLALUNAN

(Affiant)

PRC ID#1012784-Professional Teacher

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at Dipolog City.

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, LLOYD R. PASCUAL, of legal age, Filipino, single/married, a resident of Dapitan City, Zamboanga del
Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a liaison officer of Gud Moto Trading Inc. and holder and possessor of Official Receipt(OR)
No. 1726509702 for Motor vehicle with CR No.37402194-4, issued by LTO.

That on November 1, 2020, I discovered that folder containing the official receipt from LTO was lost,
and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said official receipt issued by LTO.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2021, at
Dipolog City.
 LLOYD R. PASCUAL
(Affiant)
Driver’s License#J01-05-002100

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at Dipolog City.

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ELMA VILLASICA CHERNISS, of legal age, Filipino, widow, resident of Laylay St. Estaka, Dipolog City,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am the registered owner of parcel of land pursuant to Affidavit of Self-Adjudication notarized by Dario
Mandantes under Doc.No.499, Page No. 88, Book No.XIX, Series of 2020, more particularly described as
follows:

A parcel of land known as Lot No.458-B, covered by Transfer Certificate of Title No. T-21489 located at
Disakan, Manukan, Zamboanga del Norte with an area of 11,763 square meters.

That unfortunately, the owner’s copy of the said certificate of title was lost due to heavy flood that devastated
my ancestral home in Disakan, Manukan, Zamboanga del Norte:

That I was not in Manukan that time and my mother was already dead;

That the caretaker of our ancestral home was long dead also;
That despite effort to recover the same but it was naught.

Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for the
purpose of attesting to the loss of the said Transfer Certificate of Title No.T-21489.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2021, at Dipolog
City.

ELMA RECOSOSA VILLASICA CHERNISS

(Affiant)

OSCA ID#199117-Dipolog City

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at Dipolog City.

I, ELMA VILLASICA CHERNISS, of legal age, Filipino, widow, resident of Laylay St. Estaka, Dipolog City,
Zamboanga del Norte

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, DEMOSTHENES G. EMPEYNADO,JR, of legal age, Filipino, single, a

resident of San Miguel, Polanco, Zamboanga del Norte, after having been
duly sworn in accordance with law, hereby depose and state:

That I am an employee of Department of Education(DepEd);

That I am a holder and possessor of payslips for the months of November
and December 2020 issued by my employer DepEd;

That last week, while I was trying to look for the said payslips from where I
kept it, I found out that the said payslips were lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost;

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

foregoing statements and for the purpose of attesting to the loss of the said
DepEd payslipss.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2021, at Dipolog City.

DEMOSTHENES G. EMPEYNADO,JR
(Affiant)
Driver’s License#J01-20-007270
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at

Dipolog City.

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS
I, TIMOTHY DALE B. DUNQUE, of legal age, Filipino, single, a resident of Purok Bougainvilla, Gulayon,
Dipolog City after having been duly sworn in accordance with law, hereby depose and state:

That I am a business owner of CHIQUI’S FOOD HOUSE with Certificate of Registration BIR Form 2303
issued by Bureau of Internal Revenue RDO 91. That however after it was released by the BIR, the said
certificate was lost.

That I tried to locate the said document, but it could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said BIR issued Certificate of Registration or BIR Form
No.2303.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2021, at
Dipolog City.

TIMOTHY DALE B. DUNQUE

(Affiant)
ID#_______________________
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at Dipolog City.

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS
I, REINEIR C. MURRO, of legal age, Filipino, single/married, a resident of 225 CP Garcia St., Biasong,
Dipolog City, Zamboanga del Norte after having been duly sworn in accordance with law, hereby
depose and state:

That I am the uncle of Clester Royd D. Murro, holder and possessor of Form 137(School Card),
Diploma, Good Moral Character Certificate(Honorable Dismissal), and other related documents issued
by Zamboanga del Norte National High School-Main Campus. That my nephew left me the abovesaid
documents for safekeeping

That on February 21, 2020, I discovered that folder containing the said documents was lost, and could
not be found. That the lost could be due to fire;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said Form 137(School Card), Diploma, Good Moral
Character Certificate(Honorable Dismissal), and other documents.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2021, at
Dipolog City.

REINEIR C. MURRO
(Affiant)
Driver’s License#J01-00-033000

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at Dipolog City.
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, NATHANIEL A. SUMILE, of legal age, Filipino, married, a resident of

Turno, Dipolog City, Zamboanga del Norte, after having been duly sworn in
accordance with law, hereby depose and state:

That I am a holder and possessor of an ATM card with number 0516-0466-

43 and office identification card issued by my employer Landbank of the
Philippines;

That last week, while I was trying to look for the said office ID card and my
LBP ATM card from where I kept it, I found out that the office ID card and
LBP ATM card were lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost;

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

foregoing statements and for the purpose of attesting to the loss of the said
office ID card and LBP ATM card, and request the replacement of the said
cards.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2021, at Dipolog City.

NATHANIEL A. SUMILE
(Affiant)
ID#____________________________
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at

Dipolog City.
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, CARLA G. JAMAROLIN, of legal age, Filipino, married, a resident of Dapitan City after having been
duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of PLDT Landline Plus Postpaid Sim Card with ICCD number
0319297130014174 issued by PLDT.

That on February 17, 2021, I discovered that my said Sim Card was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said Sim Card.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2021, at
Dipolog City.

CARLA G. JAMAROLIN
(Affiant)
PRC ID#0026871 valid until 8/24/2021

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at Dipolog City.
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ERLINDA GABONADA MADORABLE, of legal age, widow, Filipino, a resident of Magsaysay St.,
Miputak, Dipolog City after having been duly sworn in accordance with law, hereby depose
and state:

That I am a holder/possessor of Certificate of Full Payment and Policy Contract issued by

St.Peter Life Plans for the insurance policy of my late spouse RODOLFO DUBRIA MADORABLE
who died on February 5, 2021 at Dr. Amado B. Diaz Provincial Foundation Hospital, Midsayap,
Cotabato;

That sometime February, 2021, while I was trying to locate the said certificate and policy I
could not find it because it was lost and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements
and for the purpose of attesting to the loss of the said certificate of full payment and policy
contract.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ____ day of __________
2021, at Dipolog City.

ERLINDA G. MADORABLE
(Affiant)
Voter’s ID#7202-0068A-H1266EGM20000

SUBSCRIBED AND SWORN to before me this ___ day of ________ 2021, at Dipolog City.
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ELVIS BATERNA SARITA, of legal age, Filipino, single, a resident of Padre Ramon St.,Ext., Estaka,
Dipolog City after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of Driver’s License card issued by LTO.

That on February 12, 2021, I discovered that my wallet containing my Driver’s License ID card was
lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said Driver’s License card issued by LTO.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2021, at
Dipolog City.

ELVIS BATERNA SARITA

(Affiant)
ID#____________________

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at Dipolog City.
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, FREDDY K. TAN, of legal age, Filipino, single, resident of Sta.Cruz, Dapitan

City after having been duly sworn in accordance with law, hereby depose
and state:

That I am a holder and possessor of Certificate of Registration(CR) for

motor vehicle issued by LTO with Plate Number JAX578, CR No.8631110-5,
Engine No. 119112, Chassis No. EVER-93-44874C, MV File No.:0926-
00000000123.

That on February 1, 2021, I discovered that folder containing CR of my

vehicle was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost;

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

foregoing statements and for the purpose of attesting to the loss of the said
CR of my vehicle with plate number JAX578.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2021, at Dipolog City.

FREDDY K. TAN
(Affiant)
OSCA ID#001800-Dapitan City

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021 at

Dipolog City.

Doc.No.

Page No.
Book No.

Series of 2021

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, LAARNIE SANDE VILLACORTE, of legal age, Filipino, single, a resident of Turno, Dipolog City,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am holder and possessor of Form 137(School Card), Diploma, Good Moral Character
Certificate(Honorable Dismissal), Yearbook and other related documents issued by my school General
Santos City High School.

That on November 1, 2020, I discovered that folder containing the said documents was lost, and could
not be found. That the lost could be due to fire;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;
As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said Form 137(School Card), Diploma, Good Moral
Character Certificate(Honorable Dismissal), Yearbook and other documents.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2021, at
Dipolog City.

LAARNIE SANDE VILLACORTE

(Affiant)
Driver’s License#J01-18-002722

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at Dipolog City.

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, RONALD LIBRADILLA LOMPAYAO, of legal age, Filipino, married, a

resident of Sumirap, Tangub City, after having been duly sworn in
accordance with law, hereby depose and state:
That I am a holder and possessor of a Unified Multipurpose Identification
Card(UMID) issued by Government Service Insurance System(GSIS);

That l received my UMID card but it was defective so I returned it to GSIS

but after sometime, there was no replacement yet issued by GSIS thus I
considered it as lost;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost;

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

foregoing statements and for the purpose of attesting to the loss of the said
UMID card and request the replacement of the said card.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2021, at Dipolog City.

RONALD LIBRADILLA LOMPAYAO

(Affiant)
PRC ID#0788686
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at

Dipolog City.
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, LLOYD R. PASCUAL, of legal age, Filipino, single/married, a resident of Dapitan City, Zamboanga del
Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a liaison officer of Gud Moto Trading Inc. and holder and possessor of Official Receipt(OR)
No. 1726296180 for Motor vehicle with CR No.36182563-4, issued by LTO.

That on November 1, 2020, I discovered that folder containing the official receipt from LTO was lost,
and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said official receipt issued by LTO.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2021, at
Dipolog City.

LLOYD R. PASCUAL
(Affiant)
Driver’s License#J01-05-002100

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at Dipolog City.
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ERIC L. GONZAGA, of legal age, Filipino, single/married, a resident of Turno, Dipolog City,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of Certificate of Registration(CR) for motor vehicle issued by LTO
with Plate Number GJZ 440.

That on February 1, 2021, I discovered that folder containing CR of my vehicle was lost, and could not
be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said CR of my vehicle with plate number GJZ440.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2021, at
Dipolog City.

ERIC L. GONZAGA
(Affiant)
ID#______________

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021 at Dipolog City.

Doc.No.

Page No.

Book No.

Series of 2021
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ANALIZA SORRONDA HECHANOVA, of legal age, Filipino, single/married, a resident of Poblacion

Alto, Sergio Osmena, Zamboanga del Norte after having been duly sworn in accordance with law,
hereby depose and state:

That I am a holder and possessor of a passbook issued by First Consolidated Bank(FCB)- Dipolog City
Branch with Account Number 013-0201-004990-3.

That sometime January 2021, while I was trying to look for my said passbook from my file folder, then
I found out that my passbook was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said FCB Passbook.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2021, at
Dipolog City.

ANALIZA SORRONDA HECHANOVA

(Affiant)
PRC ID#0024264 until 9/16/2022
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2021
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, REYNALDO J. OCUPE, of legal age, Filipino, a resident of Poblacion, Polanco, Zamboanga del Norte
after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of Driver’s License issued by Land Transportation Office with
Number J01-91-013362;

That on February 7, 2021, I tried to locate the driver’s license from my wallet where I kept all of my
important document but it was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said driver’s license.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2021, at
Dipolog City.

REYNALDO J. OCUPE
(Affiant)
Driver’s License#J01-91-013362

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at Dipolog City.

DOC.NO.
PAGE NO.
BOOK NO.
SERIES OF 2021
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

We, ELVIRA ESCUADRO/KHYTHLYN MARIEL ESCUADRO/JAY ESCUADRO, all of legal age, all Filipinos, all
residents of Bonifacio St., Dipolog City, Zamboanga del Norte after having been duly sworn in
accordance with law, hereby depose and state:

That we are holders and possessors of MTOP Permit issued by LGU-Dipolog City for Motor vehicle
with CR No. 218297461, MTOP No. DPLG NO. 2020-0160, Plate No. TP-090801-33.
That we discovered that folder containing the said MTOP was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, we considered it as totally lost;

As such, we are executing this Affidavit of Loss to attest to the truth of the foregoing statements and
for the purpose of attesting to the loss of the said MTOP.

IN WITNESS WHEREOF, we have hereunto affixed our signatures this ___ day of __________ 2021, at
Dipolog City.

ELVIRA ESCUADRO/KHYTHLYN MARIEL ESCUADRO/JAY ESCUADRO

(Affiants)
ID#___________________

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021 at Dipolog City.

Doc.No.

Page No.

Book No.

Series of 2021

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x
 AFFIDAVIT OF LOSS

I, JOSE A. NORIEGA, of legal age, Filipino, married to Meirem Noriega, a resident of Turno,
Dipolog City, Zamboanga del Norte after having been duly sworn in accordance with law,
hereby depose and state:

That I am the registered owner of parcels of land, more particularly described as follows:

1.A parcel of land known as Lot No.3282-B, Psd-09-44739 covered by Transfer Certificate of
Title No. T-56068 located at Dapdap, Polanco, Zamboanga del Norte with an area of 9,096
square meters.

2. A parcel of land known as Lot No.1, Cad.837 covered by Katibayan ng Orihinal na Titulo Blg.
P-38118 located at Sinipay, Sibutad, Zamboanga del Norte with an area of 1,034 square
meters.

That unfortunately, the owner’s copy of the said certificates of title was lost due to
misplacement;

That despite effort to recover the same but it was naught.

Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements
and for the purpose of attesting to the loss of the said Transfer Certificate of Title No.T-56068
and Katibayan ng Orihinal na Titulo Blg. P-38118.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2021,
at Dipolog City.

JOSE A. NORIEGA

(Affiant)

ID#___________________________

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at Dipolog City.
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT

I, FROILAN S. JAMITO, of legal age, Filipino, married to Delia M. Jamito, a resident of Barra, Dipolog
City, Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and
state:

That I am a party to a notarized document under notarial register of Julius C. Napigquit with
Doc.No.42,Page No. 10, Book No. 38, Series of 2011;

That there was a donation in my favor from my mother Natividad Sorronda vda de Jamito in the said
document;

That however, the undersigned has already executed an Affidavit of Self-adjudication involving the
said estate/property;

That hence, the donation found on the page three(3) of the said notarized document should be
disregarded due to operation of self-adjudication which has similar effect of transfer of ownership
with the act of donation;

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

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2021, at
Dipolog City.

FROILAN S. JAMITO
(Affiant)
TIN#938-742-889

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021 at Dipolog City.

Doc.No.

Page No.

Book No.

Series of 2021
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, CARLOS G. SULAPAS, of legal age, Filipino, single/married, a resident of _______, Dipolog City,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of Official Receipt(OR) and Certificate of Registration for Motor
vehicle with Plate Number:___________, Engine No._____________issued by LTO.

That I discovered that folder containing the certificate of registration and official receipt from LTO was
lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said certificate of registration/official receipt issued by LTO.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2021, at
Dipolog City.

CARLOS G. SULAPAS
(Affiant)
ID#___________________

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021 at Dipolog City.

Doc.No.

Page No.

Book No.

Series of 2021
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, CHRISTOPHER BAGATUA REGENCIA, of legal age, Filipino, single/married, a resident of Poblacion,

Sibutad, Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose
and state:

That I am a holder and possessor of Official Receipt(OR) for Motor vehicle with Certificate of
Registration(CR) No.282907483 issued by LTO and a holder of Certificate of Registration for motor
vehicle with Plate Number JBL 809, also issued by LTO.

That on February 1, 2021, I discovered that folder containing the official receipt of my vehicle with CR
No. 282907483 from LTO and the CR of my vehicle with plate number JBL 809 were lost, and could
not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said official receipt issued by LTO and the CR of my vehicle
with plate number JBL 809.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2021, at
Dipolog City.

CHRISTOPHER BAGATUA REGENCIA

(Affiant)
Driver’s License#J01-92-013998

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021 at Dipolog City.

Doc.No.

Page No.
Book No.

Series of 2021

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, CARLOS G. SULAPAS, of legal age, Filipino, married, a resident of Sta.Filomena, Dipolog City,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a liaison officer of PETNET INC. and holder and possessor of Official Receipt(OR) No.
1694001735 for Motor vehicle with CR No.260393512 issued by LTO.

That on February 1, 2021, I discovered that folder containing the official receipt from LTO was lost,
and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said official receipt issued by LTO.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2021, at
Dipolog City.

CARLOS G. SULAPAS
(Affiant)
ID#___________________

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021 at Dipolog City.

Doc.No.
Page No.

Book No.

Series of 2021

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, NURIDJA S. JALISAN, of legal age, Filipino,married, a resident of Dicayas, Dipolog City, Zamboanga
del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of an official receipt/registration of Stihl Powersaw with Serial No.
SN S100656146 which I own;

That sometime December 2020, while I was trying to look for my said official receipt/registration from
my file folder, then I found out that my passbook was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said official receipt/registration.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2021, at
Dipolog City.

NURIDJA S. JALISAN
(Affiant)
ID#____________________
With Photo
SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2021

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, CHARMAINE E. PENADOS, of legal age, Filipino, single, with address of Obay, Polanco, Zamboanga
del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am the daughter business owner MELANIE E. PENADOS of a business with Business Name “
LANI’S LIVESTOCK BUYER AND DEALER” situated at Obay, Polanco, Zamboanga del Norte. The said
business is registered with Department of Trade and Industry(DTI) and issued a DTI registration
permit. That my mother died last year;

That in the third week of January 2021, while I was trying to arrange several office documents and
locating the said DTI registration, but it was lost and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said DTI Registration.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2021, at
Dipolog City.

CHARMAINE E. PENADOS\
(Affiant)
ID#____________________
SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2021

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, DECOROSO T. ELUMBARING, of legal age, Filipino, married, a resident of Estaka, Dipolog

City, Zamboanga del Norte after having been duly sworn in accordance with law, hereby
depose and state:

That I am one of the children of the late DIOSCORO CAGBABANUA ELUMBARING. That my
father died on March 5, 2013;

That he was the registered owner of a firearm, described as follows:

MAKE KIND CALIBER SERIAL NO.

Carbine PISTL HPRFL 6427109

That after the death of my father, we did not see the said firearm;

That our father told us when he was already sick that the said firearm was lost and he could
not locate it; That he instructed me including my other siblings to look for it but it was
nowhere to be found;

That we certify that we did not have possession of the said firearm;

That despite effort to recover the same but it was naught.

Hence, I considered it as totally lost by the family after our father’s demise.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements
and for the purpose of attesting to the loss of the said firearms.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2021,
at Dipolog City.

DECOROSO T. ELUMBARING

(Affiant)

Pag-ibig MID#1211-5353-2036

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at Dipolog City.

Doc. No.__
Page No.__
Book No.__
Series of 2021bn

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, CONCEPCION MIRASOL, of legal age, Filipino, married, a resident of Biasong, Dipolog City,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose
and state:

That I am the heir of my foster father TITO GANIA, registered owner of a parcel of land known
as Lot 40-D-1, Psd-09-017147 covered by Transfer Certificate of Title No. T-9188 located at
P.Zamora St., Biasong, Dipolog City with an area of 60 square meters.

That unfortunately, the owner’s copy of the said certificate of title was lost due to the passing
of time and nobody could trace the whereabouts of the said copy;

That despite effort to recover the same but it was naught.

Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements
and for the purpose of attesting to the loss of the said Transfer Certificate of Title No.T-9188.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2021,
at Dipolog City.
 CONCEPCION MIRASOL

(Affiant)

ID#___________________________

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at Dipolog City.

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, GLYNES G. GUEVARA, of legal age, Filipino, married, a resident of Victoria Country Homes,
Obay,Polanco, Zamboanga del Norte after having been duly sworn in accordance with law, hereby
depose and state:

That I am a holder and possessor of a passbook issued by First Consolidated Bank(FCB)- Dipolog City
Branch with Account Number 013-0201-008031-8.

That sometime December 2020, while I was trying to look for my said passbook from my file folder,
then I found out that my passbook was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said FCB Passbook.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2021, at
Dipolog City.
 GLYNES G. GUEVARA
(Affiant)
UMID ID#CRN-006-0094-6607-6
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2021

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, DALILA SULIT QUINLAN, of legal age, Filipino, married, a resident of Estaka, Dipolog City, Zamboanga
del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of OSCA(Office of the Senior Citizen’s Affair) Identification Card.

That sometime last week, while I was transacting with the grocery store and I tried to avail discount, I
found out that my OSCA ID was also lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said OSCA ID.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ____ day of ____ 2021, at Dipolog
City.
 DALILA S. QUINLAN
(Affiant)
Voter’s ID#7202-0040A-C2059DSQ20000-9

SUBSCRIBED AND SWORN to before me this ____ day of _______ 2021, at Dipolog City.
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, MAISA R. MARTEL, of legal age, Filipino, married, a resident of Ranillo St., Central Barangay, Dipolog
City after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of Driver’s License issued by Land Transporation Office and Voter’s
ID issued by COMELEC;

That on January 7, 2021, I tried to locate the driver’s license and Voter’s ID from my card holder
where I kept all of my important document but it was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said driver’s license and Voter’s ID.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2021, at
Dipolog City.

MAISA R. MARTEL
(Affiant)
ID#_____________

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2021, at Dipolog City.
Doc No. _____ IVO M. MANDANTES,CPA
Page No. _____ NOTARY PUBLIC FOR ZAMBOANGA DELNORTE
Book No. ____ VALID UNTIL 12-31-2021
Series of 2020 COMMISSION NO.SN:ZDN-DPL-013-2020
PTR NO.1945342,1/02/2020
IBP NO.095495,11/22/2019 for 2020
ATTORNEY’S ROLL NO. 65014
LAPU-LAPU ST. DIPOLOG CITY

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ANABELLE D. MONDIJAR, of legal age, Filipino, married, a resident of Sta. Filomena, Dipolog
City after having been duly sworn in accordance with law, hereby depose and state:

That I kept the Certificates of Full Payment and Plan Contract issued to the name of my spouse
FLORIANO F. MONDIJAR by PhilPlans First, Inc. for educational plan of our child1 and his
pension plan; That the educational plan has plan number 3364038228 and his pension plan
has plan number 3501908015;

That sometime October, 2020, while I was trying to locate the said certificates and plan
contracts after I renovated our house I could not find it; That it may be mixed with other
trashed documents that I disposed of;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;
As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements
and for the purpose of attesting to the loss of the said certificates of full payment and plan
contracts.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ____ day of __________
2021, at Dipolog City.

ANABELLE D. MONDIJAR
(Affiant)
Driver’s License#J01-10-002078
With photo

SUBSCRIBED AND SWORN to before me this ___ day of ________ 2021, at Dipolog City.

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ANABELLE D. MONDIJAR, of legal age, Filipino, married, a resident of Sta. Filomena, Dipolog
City after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder/possessor of Certificate of Full Payment and Plan Contract issued by

PhilPlans First, Inc. for the educational plan of my child; That the said plan has plan number
3364040792;

That sometime October, 2020, while I was trying to locate the said certificate and plan
contract after I introduced improvements and renovations on our house I could not find it;
That it may be mixed with other trashed documents that I disposed of;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;
As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements
and for the purpose of attesting to the loss of the said certificate of full payment and plan
contract.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ____ day of __________
2021, at Dipolog City.

ANABELLE D. MONDIJAR
(Affiant)
Driver’s License#J01-10-002078
With photo

SUBSCRIBED AND SWORN to before me this ___ day of ________ 2021, at Dipolog City.

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, RENARIO A. GARZON, of legal age, Filipino, married, a resident of Macleodes, Polanco, Zamboanga
del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of Driver’s License and Certificate of Registration(CR) for Motor
Vehicle issued by LTO, with Plate Number_____________, Make: Suzuki , Series: Raider 110;

That on December 28, 2020, I tried to locate the driver’s license and certificate of registration from
my wallet where I kept all of my important documents but it was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said driver’s license and CR.
IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2020, at
Dipolog City.

RENARIO A. GARZON
(Affiant)
UMID#CRN-021-1869-1891-8

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2020, at Dipolog City.

Doc No. _____ IVO M. MANDANTES,CPA

Page No. _____ NOTARY PUBLIC FOR ZAMBOANGA DELNORTE
Book No. ____ VALID UNTIL 12-31-2021
Series of 2020 COMMISSION NO.SN:ZDN-DPL-013-2020
PTR NO.1945342,1/02/2020
IBP NO.095495,11/22/2019 for 2020
ATTORNEY’S ROLL NO. 65014
LAPU-LAPU ST. DIPOLOG CITY

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, SHEM S. PARAMA, of legal age, Filipino, married, a resident of Isis, Polanco, Zamboanga del Norte
after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of receipt with number CR-018015 amounting to P500.00 dated
October 20, 2020 for downpayment of spare parts-starter clutch assembly at Yamaha-Dipolog City;

That on December 28, 2020, I tried to locate the receipt from the folder where I kept all of my
important documents and other claims but it was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.
As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said receipt.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2020, at
Dipolog City.

SHEM S. PARAMA
(Affiant)
Driver’s License #J01-10-002476

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2020, at Dipolog City.

Doc No. _____ IVO M. MANDANTES,CPA

Page No. _____ NOTARY PUBLIC FOR ZAMBOANGA DELNORTE
Book No. ____ VALID UNTIL 12-31-2021
Series of 2020 COMMISSION NO.SN:ZDN-DPL-013-2020
PTR NO.1945342,1/02/2020
IBP NO.095495,11/22/2019 for 2020
ATTORNEY’S ROLL NO. 65014
LAPU-LAPU ST. DIPOLOG CITY

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, EMMA A. MUTIA of legal age, Filipino, married, a resident of De Oro, Olingan, Dipolog City,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That, as President of EJ Agrivet Trading Corporation, I am a holder and possessor of a Receipt/Claim

Slip issued by the Register of Deeds for Dipolog City for new certificate of title of parcel of land
purchased by EJ Agrivet Trading Corporation known as Lot No. 1032-J-6, covered by TCT No.T-26642.
That the said receipt/claim slip was in possession by Alma Tomales, an attorney-in-fact of the
corporation, however she unfortunately died. That the undersigned tried to locate the receipt/claim
slip but it could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said receipt/claim slip.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2020, at
Dipolog City.

EMMA A. MUTIA
(Affiant)
Driver’s License#J01-01-034683
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2020, at Dipolog City.

Doc No. _____ IVO M. MANDANTES,CPA

Page No. _____ NOTARY PUBLIC FOR ZAMBOANGA DELNORTE
Book No. ____ VALID UNTIL 12-31-2021
Series of 2020 COMMISSION NO.SN:ZDN-DPL-013-2020
PTR NO.1945342,1/02/2020
IBP NO.095495,11/22/2019 for 2020
ATTORNEY’S ROLL NO. 65014
LAPU-LAPU ST. DIPOLOG CITY

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, RUEL G. CREUS, of legal age, Filipino, married, a resident of Poblacion South, Polanco,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose
and state:
That I am a holder and possessor of Tax Identification Number(TIN) Identification card(ID)
issued by Bureau of Internal Revenue.

That on December 17, 2020, I tried to locate my said TIN ID, but I found out that my said TIN ID
was lost, and could not be found;

That despite effort to recover the same but it was naught.

Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements
and for the purpose of attesting to the loss of the said TIN ID.

IN WITNESS WHEREOF, I have hereunto affixed my signature this 23rd day of December 2020,
at Dipolog City.

RUEL G. CREUS

(Affiant)

Driver’s License#J01-04-000469

SUBSCRIBED AND SWORN to before me this 23rd day of December 2020, at Dipolog City.

Doc No.96 IVO M. MANDANTES,CPA

Page No. 21 NOTARY PUBLIC FOR ZAMBOANGA DELNORTE
Book No. 50\ VALID UNTIL 12-31-2021
Series of 2020 COMMISSION NO.SN:ZDN-DPL-013-2020
PTR NO.1945342,1/02/2020
IBP NO.095495,11/22/2019 for 2020
ATTORNEY’S ROLL NO. 65014
LAPU-LAPU ST. DIPOLOG CITY

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, CARMELA TACUDA BURGUITE, of legal age, Filipino, married, and

resident of Olingan, Dipolog City, Zamboanga del Norte, after having been
duly sworn in accordance with law, hereby depose and state:
That I am a holder and possessor of a Passbook issued by Katipunan Bank.-
Dipolog City.

That on December 16, 2020, while I was trying to look for the said passbook
from the file where I kept it, I found out that the passbook was lost, and
could not be found;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost;

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

foregoing statements and for the purpose of attesting to the loss of the said
Passbook issued by Katipunan Bank.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2020, at Dipolog City.

CARMELA TACUDA BURGUITE

(Affiant)
PRC ID#0928393-Professional Teacher
Valid until 02/14/2021
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2020, at

Dipolog City.

Doc No. _____ IVO M. MANDANTES,CPA

Page No. _____ NOTARY PUBLIC FOR ZAMBOANGA DELNORTE
Book No. ____ VALID UNTIL 12-31-2021
Series of 2020 COMMISSION NO.SN:ZDN-DPL-013-2020
PTR NO.1945342,1/02/2020
IBP NO.095495,11/22/2019 for 2020
ATTORNEY’S ROLL NO. 65014
LAPU-LAPU ST. DIPOLOG CITY

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS
I, ROSARIO SHARON ORTEGA, Filipino, of legal age, married and a resident of Mibang,
Sta. Isabel, Dipolog City, Zamboanga del Norte after having been duly sworn in accordance
with law, hereby depose and state:

That I am a holder and possessor of an official receipt issued by MLhuillier for a pawned jewelry of
Ring 2.0g 18K with Receipt No.PTN 0553-2020-00405 in the amount of P3,800.00 pawned on April
18,2020.

That on December 14, 2020, I found out that my receipt was lost, I tried to locate the receipt but it
was really lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said official receipt of MLhuillier.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2020, at
Dipolog City.

ROSARIO SHARON S. ORTEGA

(Affiant)
UMID#CRN-006-0127-1448-5

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2020, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2020

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x
 AFFIDAVIT OF LOSS

I, LORENA JAUGIN MAGHINAY, of legal age, Filipino, married, a resident of Sitog, Katipunan,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of a Philippine Passport issued by the Department of Foreign Affairs.

That on December 7, 2020, my wallet and passport was lost;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said passport.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2020, at
Dipolog City.

LORENA JAUGIN MAGHINAY

(Affiant)
Philhealth#02-025760107-3

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2020, at Dipolog City.

Doc No. _____ IVO M. MANDANTES,CPA

Page No. _____ NOTARY PUBLIC FOR ZN,CITIES OF DIPOLOG/DAPITAN
Book No. ____ VALID UNTIL 12-31-2021
Series of 2020 COMMISSION NO.SN:ZDN-DPL-013-2020
PTR NO.1945342,1/02/2020-Dipolog City
IBP NO.095495,11/22/2019 for CY2020
ATTORNEY’S ROLL NO. 65014
LAPU-LAPU ST. ESTAKA,DIPOLOG CITY

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x
 AFFIDAVIT OF LOSS

I, EMMA A. MUTIA, of legal age, Filipino, married, a resident of De Oro, Olingan, Dipolog City,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose
and state:

That I am the President of EJ AGRIVET TRADING CORP, a corporation registered under the
Philippines, who is the buyer/owner of a parcel of land covered by Transfer Certificate of Title
No.128-2018000311 located at Galas, Dipolog City.

That the said parcel of land was sold to the corporation by its registered owner pursuant to
Deed of Absolute Sale executed before notary public Cresencio N. Palpagan,Jr. with Doc. No.
2421, Page No. 74, Book No. CXVI, Series of 2018;

That on December 8, 2020, while I was looking for the Deed of Absolute Sale document I found
out that the original copy of the said deed was lost.

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements
and for the purpose of attesting to the loss of the said Deed of Absolute Sale.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2020,
at Dipolog City.

EMMA A. MUTIA
(Affiant)
ID#____________________________

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2020, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2020
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ERIC O. SAGUIN, of legal age, Filipino, married, a resident of Gen. Luna St., Estaka, Dipolog City after
having been duly sworn in accordance with law, hereby depose and state:

That I am the spouse of ANALYN TOME BELHOT, a graduate of a baccalaureate degree at Saint
Vincent’s College, Dipolog City. My spouse was a holder and possessor of a Diploma with Special
Order from CHED issued by said college.

That in the first week of December, 2020, while I was trying to locate the said diploma and with
Special Order because my spouse, who is an overseas worker, was looking for it, but it was lost and
could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said Diploma and its Special Order.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2020, at
Dipolog City.

ERIC O. SAGUIN
(Affiant)
ID#_______________________________

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2020, at Dipolog City.

Doc No. _____ IVO M. MANDANTES,CPA

Page No. _____ NOTARY PUBLIC FOR ZAMBOANGA DELNORTE
Book No. ____ VALID UNTIL 12-31-2021
Series of 2020 COMMISSION NO.SN:ZDN-DPL-013-2020
PTR NO.1945342,1/02/2020
IBP NO.095495,11/22/2019 for 2020
ATTORNEY’S ROLL NO. 65014
LAPU-LAPU ST. DIPOLOG CITY
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF JUSTIFICATION

I, ROLIE S. MIRANDA, of legal age, Filipino, single, a resident of 034 A.Bonifacio St.,, Barra, Dipolog City
after having been duly sworn in accordance with law, hereby depose and state:

That I am the Geodetic Engineer who surveyed and processed the approval of Segregation Survey
Plan of parcel of land known as Lot 1, SGS-09-000675 situated at Estaka, Dipolog City which was
approved by Rogelio C. Lagat, OIC-Regional Technical Director of DENR-IX.

That the said approved survey plan had indicated that there is a Road in the southern portion of Lot 1;

That the said road is described and indicated with “dotted line”;

That however there is no really road in that said approved survey plan because the said “dotted line”
merely suggest that there was available area for road;

That the road right of the said approved survey plan really exists at the northern part of Lot 1, not in
the southern part as indicated by the approved survey;

That I execute this affidavit of justification to attest the foregoing statement and to correct the
already approved survey since there was no really existing road at the southern part of Lot 1;

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2020, at
Dipolog City.

ROLIE S. MIRANDA
(Affiant)
Driver’s License#J01-01-034646

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2020, at Dipolog City.

Doc No. _____ IVO M. MANDANTES,CPA

Page No. _____ NOTARY PUBLIC FOR ZAMBOANGA DELNORTE
Book No. ____ VALID UNTIL 12-31-2021
Series of 2020 COMMISSION NO.SN:ZDN-DPL-013-2020
PTR NO.1945342,1/02/2020
IBP NO.095495,11/22/2019 for 2020
ATTORNEY’S ROLL NO. 65014
LAPU-LAPU ST. DIPOLOG CITY
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, GLENN CAYONGCONG VERINIO, of legal age, Filipino, married, a resident of Baybay, Galas, Dipolog
City after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of Driver’s License card with No.J01-05-000775 issued by LTO, SSS
ID, and Philhealth ID.

That today, December 1, 2020, I discovered that my wallet containing my Driver’s License ID card, SSS
ID card and Philhealth ID was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said Driver’s License card issued by LTO, SSS ID, and
Philhealth ID.
IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2020, at
Dipolog City.

GLENN CAYONGCONG VERINIO

(Affiant)
Driver’s License#J01-05-000775

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2020, at Dipolog City.

Doc No. _____ IVO M. MANDANTES,CPA

Page No. _____ NOTARY PUBLIC FOR ZAMBOANGA DELNORTE
Book No. ____ VALID UNTIL 12-31-2021
Series of 2020 COMMISSION NO.SN:ZDN-DPL-013-2020
PTR NO.1945342,1/02/2020
IBP NO.095495,11/22/2019 for 2020
ATTORNEY’S ROLL NO. 65014
LAPU-LAPU ST. DIPOLOG CITY

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT

I, AUGUSTO INFANTE ALFONSO, of legal age, Filipino,

single/married/widow/er, a resident of Purok Orchids, Sicayab, Dipolog City,
after having been duly sworn in accordance with law, hereby depose and
state:

That I am the brother Editha Alfonso Nangcas who was the mortgagee of the
parcel of irrigated Riceland situated at Tigbawan, Pigcawayan, North
Cotabato which was mortgaged by Vicente Ragonton. That I made
contribution in the amount of P50,000.00 to the money loaned by my sister
Editha to Vicente;
That my said sister and Vicente Ragonton had already died;

That I did not and have not receive any money from my brother-in-law
Onesimo Nangcas as refund or payment to the contribution I made to my
sister contrary to his claim that he made refund or payment to me;

That there was no payment made to me;

That I hereby attest that the foregoing statements are true and correct.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2020, at Dipolog City.

AUGUSTO INFANTE ALFONSO

(Affiant)
AFPICS NR.OTAG-EP-667770-105307
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2020, at

Dipolog City.

Doc No. _____ IVO M. MANDANTES,CPA

Page No. _____ NOTARY PUBLIC FOR ZAMBOANGA DELNORTE
Book No. ____ VALID UNTIL 12-31-2021
Series of 2020 COMMISSION NO.SN:ZDN-DPL-013-2020
PTR NO.1945342,1/02/2020
IBP NO.095495,11/22/2019 for 2020
ATTORNEY’S ROLL NO. 65014
LAPU-LAPU ST. DIPOLOG CITY

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, JULIETO G. SAMARINTA, of legal age, Filipino, married, a resident of

Biayon, Sergio Osmena, Zamboanga del Norte, after having been duly
sworn in accordance with law, hereby depose and state:
That I am a holder and possessor of a Unified Multipurpose Identification
Card(UMID) issued by Government Service Insurance System(GSIS) and my
Landbank of the Philippines(LBP) ATM card;

That last week, while I was trying to look for the said UMID card and my LBP
ATM card from where I kept it, I found out that the UMID card and LBP ATM
card were lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost;

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

foregoing statements and for the purpose of attesting to the loss of the said
UMID card and LBP ATM card, and request the replacement of the said
cards.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2020, at Dipolog City.

JULIETO G. SAMARINTA
(Affiant)
DPWH Employee ID#97L0034
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2020, at

Dipolog City.

Doc No. _____ IVO M. MANDANTES,CPA

Page No. _____ NOTARY PUBLIC FOR ZAMBOANGA DELNORTE
Book No. ____ VALID UNTIL 12-31-2021
Series of 2020 COMMISSION NO.SN:ZDN-DPL-013-2020
PTR NO.1945342,1/02/2020
IBP NO.095495,11/22/2019 for 2020
ATTORNEY’S ROLL NO. 65014
LAPU-LAPU ST. DIPOLOG CITY
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, JEFFREY E. ANDILAB, of legal age, Filipino, single/married, a resident of

Purok Parpagayo, Olingan, Dipolog City, after having been duly sworn in
accordance with law, hereby depose and state:

That I am a holder and possessor of a Certification issued by Armed Forces

and Police Mutual Benefits Association, Inc.(AFPMBAI) certifying that I am a
member of AFPMBAI;

That on November 25, 2020, while I was trying to look for the said
certification from my file where I kept it, I found out that the certification
was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost;

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

foregoing statements and for the purpose of attesting to the loss of the said
certification issued by AFPMBAI.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2020, at Dipolog City.

JEFFREY E. ANDILAB
(Affiant)
Driver’s License#J01-15-000004
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2020, at

Dipolog City.

Doc No. _____ IVO M. MANDANTES,CPA

Page No. _____ NOTARY PUBLIC FOR ZAMBOANGA DELNORTE
Book No. ____ VALID UNTIL 12-31-2021
Series of 2020 COMMISSION NO.SN:ZDN-DPL-013-2020
PTR NO.1945342,1/02/2020
IBP NO.095495,11/22/2019 for 2020
ATTORNEY’S ROLL NO. 65014
LAPU-LAPU ST. DIPOLOG CITY
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, APRONIANO T. DANCALAN, of legal age, Filipino, single/married, a

resident of San Antonio, Polanco, Zamboanga del Norte, after having been
duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of a Passbook with Account No. 004677

issued by FICCO- Dipolog City Branch;

That on November, 2020, while I was trying to look for the said passbook
from my file where I kept it, I found out that the passbook was lost, and
could not be found;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost;

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

foregoing statements and for the purpose of attesting to the loss of the said
Passbook issued by FICCO, and request the replacement of the said
passbook.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2020, at Dipolog City.

APRONIANO T. DANCALAN
(Affiant)
Driver’s License#J01-04-002441
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2020, at

Dipolog City.

Doc No. _____ IVO M. MANDANTES,CPA

Page No. _____ NOTARY PUBLIC FOR ZAMBOANGA DELNORTE
Book No. ____ VALID UNTIL 12-31-2021
Series of 2020 COMMISSION NO.SN:ZDN-DPL-013-2020
PTR NO.1945342,1/02/2020
IBP NO.095495,11/22/2019 for 2020
ATTORNEY’S ROLL NO. 65014
 LAPU-LAPU ST. DIPOLOG CITY

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, RITO I. TAN, Jr., of legal age, Filipino, single, a resident of Siparok, Jose Dalman, Zamboanga del
Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of an Automated Teller Machine(ATM) with SA #2556163556 issued
by Land Bank of the Philippines(LBP)- Sindangan, Zamboanga del Norte Branch .

That on November 24, 2020, I discovered that the LBP ATM card was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said LBP ATM card and thereafter requesting replacement
thereon.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2020, at
Dipolog City.

RITO I. TAN, JR.

(Affiant)
Drivers License#J07-18-004948
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2020, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2020
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ARSENIO LLIDO,JR, of legal age, Filipino, married, a resident of Lalawan, Dicayas, Dipolog City after
having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of an Automated Teller Machine(ATM) cash card issued by Banco de
Oro(BDO)-Rizal Ave., Dipolog City Branch .

That on November 21, 2020, I discovered that the BDO ATM card was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said BDO ATM card and thereafter requesting replacement
thereon.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2020, at
Dipolog City.

ARSENIO LLIDO,JR.
(Affiant)
ID#_______________________

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2020, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2020

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ALMA A. TOMALES, of legal age, Filipino, married, a resident of Igot, Turno, Dipolog City after
having been duly sworn in accordance with law, hereby depose and state:

That I am the attorney-in-fact of buyer/holder and possessor of an original BIR stamped Deed of
Absolute Sale of Land notarized by Ivo M. Mandantes under Doc. No. 1239, Page No. 48, Book No. III,
Series of 2019. That however after it was stamped by the BIR, the said original copy of the Deed of
Sale duly stamped by BIR was lost.

That I tried to locate the said document, but it could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said BIR stamped Deed of Absolute Sale.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2020, at
Dipolog City.

ALMA A. TOMALES
(Affiant)
SSS#10-0556680-7
 With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2020, at Dipolog City.

Doc No. _____ IVO M. MANDANTES,CPA

Page No. _____ NOTARY PUBLIC FOR ZAMBOANGA DELNORTE
Book No. ____ VALID UNTIL 12-31-2021
Series of 2020 COMMISSION NO.SN:ZDN-DPL-013-2020
PTR NO.1945342,1/02/2020
IBP NO.095495,11/22/2019 for 2020
ATTORNEY’S ROLL NO. 65014
LAPU-LAPU ST. DIPOLOG CITY

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF EXISTING ROAD

We, NANCY C. LAURQUE, of legal age, Filipino, single/married, a resident

of Pob.North, Polanco, Zamboanga del Norte; OSCAR C. LAURQUE, of legal
age, Filipino, single/married, a resident of Pob.North, Polanco, Zamboanga
del Norte; ROGER C. LAURQUE, of legal age, Filipino, single/married, a
resident of Pob.North, Polanco, Zamboanga del Norte; and DANNY C.
LAURQUE, of legal age, Filipino, single/married, a resident of Pob.North,
Polanco, Zamboanga del Norte after having been duly sworn in accordance
with law, hereby depose and state:

That we are one of the co-owners of parcel of land known as Lot 4360-
N,PSD-09-014306 OLT, with an area of 83,457 square meters located at
Labrador(then part of Letapan), Polanco, Zamboanga del Norte;
That the said parcel of land has an existing road of six(6) meters wide
traversing within its location and boundaries; That we will not alter the
prepared subdivision plan by the geodetic engineer as it is;

That the undersigned do not claim any personal right but rightfully express
that the right of easement for the said road belongs to the government and
all beneficial users, without cost;

As such, we are executing this Affidavit to attest to the truth of the

foregoing statements.

IN WITNESS WHEREOF, we have hereunto affixed our signatures this ___ day
of __________ 2020, at Dipolog City.

NANCY C. LAURQUE OSCAR C. LAURQUE ROGER C. LAURQUE

DANNY C.LAURQUE
(Affiant) (Affiant) (Affiant) (Affiant)
ID#____________ ID#___________ ID#____________
ID#_____________

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2020, at

Dipolog City.

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS
I, QUIRINO FUTALAN SUAN, of legal age, Filipino, married, a resident of
Pob.North, Pinan, Zamboanga del Norte, after having been duly sworn in
accordance with law, hereby depose and state:

That I am a holder and possessor of a Passbook with Account No. 67604

under Cash Advance Storage Account issued by PPSLAI;

That on March, 2020, while I was trying to look for the said passbook from
my file where I kept it, I found out that the passbook was lost, and could not
be found;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost;

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

foregoing statements and for the purpose of attesting to the loss of the said
Passbook issued by PPSLAI.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2020, at Dipolog City.

QUIRINO FUTALAN SUAN

(Affiant)
PNP ID#17J300505
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2020, at

Dipolog City.

Doc No. _____ IVO M. MANDANTES,CPA

Page No. _____ NOTARY PUBLIC FOR ZAMBOANGA DELNORTE
Book No. ____ VALID UNTIL 12-31-2021
Series of 2020 COMMISSION NO.SN:ZDN-DPL-013-2020
PTR NO.1945342,1/02/2020
IBP NO.095495,11/22/2019 for 2020
ATTORNEY’S ROLL NO. 65014
LAPU-LAPU ST. DIPOLOG CITY
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, LLOYD R. PASCUAL, of legal age, Filipino, single/married, a resident of Dapitan City, Zamboanga del
Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a liaison officer of Gud Moto Trading Inc. and holder and possessor of Official Receipt(OR)
No. 1517685050 for Motor vehicle with CR No.182661555; OR No.927782682 for Motor vehicle with
CR No.249560231; OR No.1198459135 for Motor vehicle with CR No. 286197704, all issued by LTO.

That on November 1, 2020, I discovered that folder containing the official receipts from LTO was lost,
and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said official receipts issued by LTO.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2020, at
Dipolog City.

LLOYD R. PASCUAL
(Affiant)
Driver’s License#J01-05-002100

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2020, at Dipolog City.

Doc No. _____ IVO M. MANDANTES,CPA

Page No. _____ NOTARY PUBLIC FOR ZAMBOANGA DELNORTE
Book No. ____ VALID UNTIL 12-31-2021
Series of 2020 COMMISSION NO.SN:ZDN-DPL-013-2020
PTR NO.1945342,1/02/2020
IBP NO.095495,11/22/2019 for 2020
ATTORNEY’S ROLL NO. 65014
LAPU-LAPU ST. DIPOLOG CITY
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, RICARDO O. GESTOPA, of legal age, Filipino, single/married, a resident of Dapitan City, Zamboanga
del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of Driver’s License card with No.J01-14-003454 issued by LTO.

That on November 1, 2020, I discovered that my LTO ID card was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said Driver’s License card issued by LTO.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2020, at
Dipolog City.

RICARDO O. GESTOPA
(Affiant)
Driver’s License#J01-14-003454

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2020, at Dipolog City.

Doc No. _____ IVO M. MANDANTES,CPA

Page No. _____ NOTARY PUBLIC FOR ZAMBOANGA DELNORTE
Book No. ____ VALID UNTIL 12-31-2021
Series of 2020 COMMISSION NO.SN:ZDN-DPL-013-2020
PTR NO.1945342,1/02/2020
IBP NO.095495,11/22/2019 for 2020
ATTORNEY’S ROLL NO. 65014
LAPU-LAPU ST. DIPOLOG CITY
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, EVELYN D. BENITEZ, of legal age, Filipino, married, a resident of Sto.Nino, Polanco, Zamboanga del
Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of an Automated Teller Machine(ATM) cash card issued by Land
Bank of the Philippines(LBP)-Dipolog City Branch .

That on November 2, 2020, I discovered that the LBP ATM card was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said LBP ATM card and thereafter requesting replacement
thereon.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2020, at
Dipolog City.

EVELYN D. BENITEZ
(Affiant)
CTC#CCI201917570902

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2020, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2020
]

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, REY L. PURO, of legal age, Filipino, married, a resident of Sicayab, Dipolog City after having
been duly sworn in accordance with law, hereby depose and state:

That I am a holder/possessor of Certificate of Full Payment issued by St.Peter Life Plans for my
insurance policy;

That sometime October, 2020, while I was trying to locate the said certificate I could not find it
because it was lost and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements
and for the purpose of attesting to the loss of the said certificate of full payment.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ____ day of __________
2020, at Dipolog City.

REY L. PURO
(Affiant)
Driver’s License#J01-02-038956

SUBSCRIBED AND SWORN to before me this ___ day of ________ 2020, at Dipolog City.

Doc No. _____ IVO M. MANDANTES,CPA

Page No. _____ NOTARY PUBLIC FOR ZAMBOANGA DELNORTE
Book No. ____ VALID UNTIL 12-31-2021
Series of 2020 COMMISSION NO.SN:ZDN-DPL-013-2020
PTR NO.1945342,1/02/2020
IBP NO.095495,11/22/2019 for 2020
ATTORNEY’S ROLL NO. 65014
LAPU-LAPU ST. DIPOLOG CITY
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF PERSONAL CIRCUMSTANCE & EXCLUSIVE PROPERTY

I, MANUEL PAMPILO, of legal age, Filipino, married to Aurelia Neri, a resident of Dicayas, Dipolog City
after having been duly sworn in accordance with law, hereby depose and state:

That I am an owner of parcel of land covered by Transfer Certificate of Title No.T-35824 issued by
ROD-Dipolog City.

That I am married to Aurelia Neri;

That my share of the said parcel of land was sold without the consent of my spouse since the said
property is my exclusive property hence marital consent is not required.

That I attest to the truthfulness of the foregoing statement.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2020, at
Dipolog City.

MANUEL PAMPILO
(Affiant)
ID#__________________

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2020, at Dipolog City.
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, MIA HUANG- PULVERA, of legal age, Filipino, married, a resident of T.Claudio St., Dipolog City after
having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of Sim Card with number 09177241927 issued by Globe Telecom.

That on October 24, 2020, I discovered that my said Sim Card was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said Sim Card.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2020, at
Dipolog City.

MIA HUANG PULVERA

(Affiant)
Driver’s License#J01-07-003325
Until 8/20/2024

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2020, at Dipolog City.

Doc No. _____ IVO M. MANDANTES,CPA

Page No. _____ NOTARY PUBLIC FOR ZAMBOANGA DELNORTE
Book No. ____ VALID UNTIL 12-31-2021
Series of 2020 COMMISSION NO.SN:ZDN-DPL-013-2020
PTR NO.1945342,1/02/2020
IBP NO.095495,11/22/2019 for 2020
ATTORNEY’S ROLL NO. 65014
LAPU-LAPU ST. DIPOLOG CITY

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, AIDA ORTEGA IGNACIO, of legal age, Filipino, married, a resident of Estaka, Dipolog City after having
been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of original copy of Motorized Tricycle Operator’s Permit(MTOP) with
the following records;Make:Yamaha, Motor No.34C2008229, Chassis No.34C2008311, Registration
No. CR#863169206,Plate No.JY-7519, DPLG No.2018-1508 issued by LGU of Dipolog City in favor of my
late mother PUREZA L. ORTEGA.

That on October 22, 2020, I discovered that my file folder containing the original copy of the said
MTOP was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said MTOP.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2020, at
Dipolog City.

AIDA O. IGNACIO
(Affiant)
ID#____________________
SUBSCRIBED AND SWORN to before me this ___ day of _________ 2020, at Dipolog City.

Doc No. _____ IVO M. MANDANTES,CPA

Page No. _____ NOTARY PUBLIC FOR ZAMBOANGA DELNORTE
Book No. ____ VALID UNTIL 12-31-2021
Series of 2020 COMMISSION NO.SN:ZDN-DPL-013-2020
PTR NO.1945342,1/02/2020
IBP NO.095495,11/22/2019 for 2020
ATTORNEY’S ROLL NO. 65014
LAPU-LAPU ST. DIPOLOG CITY

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, NICOLAS L. RONQUILLO, of legal age, Filipino, married, a resident of Anastacio, Polanco, Zamboanga
del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of policy for memorial plan with PNC Number 539087-7 issued by
Pacific Plans, Inc.

That on September 22, 2020, I discovered that my file folder containing the original copy of the said
policy was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said policy.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2020, at
Dipolog City.

NICOLAS L. RONQUILLO
(Affiant)
ID#____________________
SUBSCRIBED AND SWORN to before me this ___ day of _________ 2020, at Dipolog City.

Doc No. _____ IVO M. MANDANTES,CPA

Page No. _____ NOTARY PUBLIC FOR ZAMBOANGA DELNORTE
Book No. ____ VALID UNTIL 12-31-2021
Series of 2020 COMMISSION NO.SN:ZDN-DPL-013-2020
PTR NO.1945342,1/02/2020
IBP NO.095495,11/22/2019 for 2020
ATTORNEY’S ROLL NO. 65014
LAPU-LAPU ST. DIPOLOG CITY

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, JORGE B. ELOPRE, of legal age, Filipino, married, a resident of Sto.Niño, Polanco,

Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose
and state:

That I am one of the Heirs of LEONCIO ELOPRE, registered owner of a parcel of land known as
Lot No.4588-E, Psd-201512 covered by Transfer Certificate of Title No. T-48051 located at
Sto.Niño, Polanco, Zamboanga del Norte with an area of 45, 413 square meters.

That unfortunately, the owner’s copy of the said certificate of title was lost due to
misplacement;

That despite effort to recover the same but it was naught.

Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements
and for the purpose of attesting to the loss of the said Transfer Certificate of Title No.T-48051.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2020,
at Dipolog City.
 JORGE B. ELOPRE

(Affiant)

DILG ID#097210026-08-Sto.Nino, Polanco, ZN

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2020, at Dipolog City.

Doc No. ____ IVO M. MANDANTES,CPA

Page No. __ NOTARY PUBLIC FOR ZAMBOANGA DELNORTE
Book No. __ VALID UNTIL 12-31-2021
Series of 2020 COMMISSION NO.SN:ZDN-DPL-013-2020
PTR NO.1945342,1/02/2020
IBP NO.095495,11/22/2019 for 2020
ATTORNEY’S ROLL NO. 65014
LAPU-LAPU ST. DIPOLOG CITY

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ELIZABETH M.PIZON, of legal age, Filipino, married, a resident of Patawag, Labason,

Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose
and state:

That I was a possessor and holder of a Pantawid Pamilyang Pilipino Program(4Ps) identification
card issued by Department of Social Welfare and Development(DSWD).

That on January 20, 2020, I was at the Fatima Liloy Public Market when my bag containing
several important documents including my 4Ps ID was taken by unknown person and thus my
4Ps ID was lost and could not be found;

That despite effort to recover the same but it was naught.

Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements
and for the purpose of attesting to the loss of the said 4Ps ID.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2020,
at Dipolog City.
 ELIZABETH M.PIZON

(Affiant)

Liloy, ZN Health Certificate No. LIL-699,Lilioy,ZN

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2020, at Dipolog City.

Doc No. ____ IVO M. MANDANTES,CPA

Page No. __ NOTARY PUBLIC FOR ZAMBOANGA DELNORTE
Book No. __ VALID UNTIL 12-31-2021
Series of 2020 COMMISSION NO.SN:ZDN-DPL-013-2020
PTR NO.1945342,1/02/2020
IBP NO.095495,11/22/2019 for 2020
ATTORNEY’S ROLL NO. 65014
LAPU-LAPU ST. DIPOLOG CITY

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, JOY SHEILA CHIONG PASCO, of legal age, Filipino, married, a resident of Dansullan, Polanco,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of Driver’s License card issued by LTO, PRC ID card as teacher issued
by PRC, UMID ID card issued by GSIS, and NCIP ID card issued by NCIP.

That on September 22, 2020, I discovered that my bag containing those ID cards was taken and lost,
and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said Driver’s License card issued by LTO, PRC ID card as
teacher issued by PRC, UMID ID card issued by GSIS, and NCIP ID card issued by NCIP.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2020, at
Dipolog City.

JOY SHEILA CHIONG PASCO

(Affiant)
Driver’s License#J01-14-001250s
SUBSCRIBED AND SWORN to before me this ___ day of _________ 2020, at Dipolog City.

Doc No. _____ IVO M. MANDANTES,CPA

Page No. _____ NOTARY PUBLIC FOR ZAMBOANGA DELNORTE
Book No. ____ VALID UNTIL 12-31-2021
Series of 2020 COMMISSION NO.SN:ZDN-DPL-013-2020
PTR NO.1945342,1/02/2020
IBP NO.095495,11/22/2019 for 2020
ATTORNEY’S ROLL NO. 65014
LAPU-LAPU ST. DIPOLOG CITY

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, MA. CRISTINA H. MANDALUNES, of legal age, Filipino, a resident of Dipolog City, Zamboanga
del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a Senior High School Teacher II employed by Department of Education. That I was a
issued and possessor of pay slip for the month of June 2020 by DepEd.

That sometime last week of July 2020 I found out that my Pay Slip for June 2020 as Senior High
School Teacher II was lost, and could not be found;

That despite effort to recover the same but it was naught.

Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements
and for the purpose of attesting to the loss of the said Pay Slip for June 2020.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2020,
at Dipolog City.
 MA. CRISTINA H. MANDALUNES

(Affiant)

DepEd Employee ID#5020075-Dipolog City National High School

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2020, at Dipolog City.

Doc No. ____ IVO M. MANDANTES,CPA

Page No. __ NOTARY PUBLIC FOR ZAMBOANGA DELNORTE
Book No. __ VALID UNTIL 12-31-2021
Series of 2020 COMMISSION NO.SN:ZDN-DPL-013-2020
PTR NO.1945342,1/02/2020
IBP NO.095495,11/22/2019 for 2020
ATTORNEY’S ROLL NO. 65014
LAPU-LAPU ST. DIPOLOG CITY

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, EFREN O. PACTORES, of legal age, Filipino, married, a resident of Mangidkid, Plaridel, Misamis
Occidental after having been duly sworn in accordance with law, hereby depose and state:

That I am the authorized driver of a motor vehicle registered under the name of Calamba Glass Supply
with CR No.76893250,Make:Suzuki, MV File No.0751-014348-03, Plate No.GGM 860 issued by LTO;

That first week of September, 2020, I was driving the said vehicle then I found out that the original
Plate Number plates attached to the vehicle were lost, I tried to locate the said plate but it was
naught, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the plate numbers.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2020, at
Dipolog City.

EFREN O.PACTORES
(Affiant)
Driver’s License#X01-19-002878
SUBSCRIBED AND SWORN to before me this ___ day of _________ 2020, at Dipolog City.

Doc No. _____ IVO M. MANDANTES,CPA

Page No. _____ NOTARY PUBLIC FOR ZAMBOANGA DELNORTE
Book No. ____ VALID UNTIL 12-31-2021
Series of 2020 COMMISSION NO.SN:ZDN-DPL-013-2020
PTR NO.1945342,1/02/2020
IBP NO.095495,11/22/2019 for 2020
ATTORNEY’S ROLL NO. 65014
LAPU-LAPU ST. DIPOLOG CITY

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ALMA P.GERODIAS, Filipino, of legal age, single and a resident of Turno, Dipolog City,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and
state:

That I am a possessor of an official receipt issued by MLhuillier for a pawned jewelry of Necklace 14K
with pendant 18K with Receipt No.0448-2020-00270 in the amount of P4,600.00 pawned on February
18,2020.

That in September 2020, I found out that my receipt was lost, I tried to locate the receipt but it was
really lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said official receipt of MLhuillier.
IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2020, at
Dipolog City.

ALMA P.GERODIAS
(Affiant)
Voters ID#72020199AJ2678APG200008

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2020, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2020

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, TITA A. MAINQUE, of legal age, Filipino, married, a resident of Poblacion North, Polanco
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose
and state:

That I am a holder/possessor of Certificate of Full Payment issued by St.Peter Life Plans for my
insurance policy;

That sometime September, 2020, while I was trying to locate the said certificate I could not
find it because it was lost and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;
As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements
and for the purpose of attesting to the loss of the said certificate of full payment.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ____ day of __________
2020, at Dipolog City.

TITA A. MAINQUE
(Affiant)
UMID#CRN-006-0121-4694-3

SUBSCRIBED AND SWORN to before me this ___ day of ________ 2020, at Dipolog City.

Doc No. _____ IVO M. MANDANTES,CPA

Page No. _____ NOTARY PUBLIC FOR ZAMBOANGA DELNORTE
Book No. ____ VALID UNTIL 12-31-2021
Series of 2020 COMMISSION NO.SN:ZDN-DPL-013-2020
PTR NO.1945342,1/02/2020
IBP NO.095495,11/22/2019 for 2020
ATTORNEY’S ROLL NO. 65014
LAPU-LAPU ST. DIPOLOG CITY

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, MARICEL P. VILLADA, of legal age, Filipino, married, a resident of Purok 2, Bacuyong, Pi ñan
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose
and state:

That I am a holder/possessor of receipt of pawned jewelry issued by MLhuillier Pawnshop

with Receipt No. 0991-2020-00020;

That sometime August, 2020, while I was trying to locate the said receipt I could not find it
because it was lost and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;
As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements
and for the purpose of attesting to the loss of the said receipt.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ____ day of __________
2020, at Dipolog City.

MARICEL P. VILLADA
(Affiant)
Postal ID#PRN M83190425538P

SUBSCRIBED AND SWORN to before me this ___ day of ________ 2020, at Dipolog City.

Doc No. _____ IVO M. MANDANTES,CPA

Page No. _____ NOTARY PUBLIC FOR ZAMBOANGA DELNORTE
Book No. ____ VALID UNTIL 12-31-2021
Series of 2020 COMMISSION NO.SN:ZDN-DPL-013-2020
PTR NO.1945342,1/02/2020
IBP NO.095495,11/22/2019 for 2020
ATTORNEY’S ROLL NO. 65014
LAPU-LAPU ST. DIPOLOG CITY

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, MA.AECEL M. BUSTALIÑO, of legal age, Filipino, a resident of Pob.South, Polanco, Zamboanga del
Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of Certificate of Registration(CR) for Motor Vehicle issued by LTO,
with CR No. 283013334, Engine No.E3R2E-1613227,Make:Yamaha;

That last week of August 28, 2020, I tried to locate the certificate of registration from the folder
where I kept all of my important documents and other claims but it was lost, and could not be found;
That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said CR.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2020, at
Dipolog City.

MA. AECEL M. BUSTALIÑO

(Affiant)
ID#______________________

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2020, at Dipolog City.

Doc No. _____ IVO M. MANDANTES,CPA

Page No. _____ NOTARY PUBLIC FOR ZAMBOANGA DELNORTE
Book No. ____ VALID UNTIL 12-31-2021
Series of 2020 COMMISSION NO.SN:ZDN-DPL-013-2020
PTR NO.1945342,1/02/2020
IBP NO.095495,11/22/2019 for 2020
ATTORNEY’S ROLL NO. 65014
LAPU-LAPU ST. DIPOLOG CITY
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, VICTOR G. LAPUT, of legal age, Filipino, married, a resident of P.Ramon Est.,Estaka, Dipolog City
after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of an original copy of Official Receipt No.1635849644 and CR wit No.
67959011 issued by LTO for my vehicle with Plate No. JBB408 which I bought from Jose Rey Hamoy.

That last week of July 2020, while I was trying to look for my said official receipt and Certificate of
Registration from my file folder, then I found out that the Official receipt and CR were lost, and could
not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said LTO Official Receipt and CR.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2020, at
Dipolog City.

VICTOR G. LAPUT
(Affiant)
Driver’s License#J01-97-024782
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2020, at Dipolog City.

Doc No. _____ IVO M. MANDANTES,CPA

Page No. _____ NOTARY PUBLIC FOR ZAMBOANGA DELNORTE
Book No. ____ VALID UNTIL 12-31-2021
Series of 2020 COMMISSION NO.SN:ZDN-DPL-013-2020
PTR NO.1945342,1/02/2020
IBP NO.095495,11/22/2019 for 2020
ATTORNEY’S ROLL NO. 65014
LAPU-LAPU ST. DIPOLOG CITY
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ELMA S. LOYLOY, of legal age, Filipino, married, a resident of Turno, DIpolog City, Zamboanga
del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder/possessor of receipt of pawned jewelry issued by Cebuana Lhuillier

Pawnshop Dipolog 1 Branch with Ticket N.503035GD52807;

That sometime August, 2020, while I was trying to locate the said receipt I could not find it
because it was lost and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements
and for the purpose of attesting to the loss of the said receipt.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2020,
at Dipolog City.

ELMA S. LOYLOY
(Affiant)
PRC ID#0058915

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2020, at Dipolog City.

Doc No. _____ IVO M. MANDANTES,CPA

Page No. _____ NOTARY PUBLIC FOR ZAMBOANGA DELNORTE
Book No. ____ VALID UNTIL 12-31-2021
Series of 2020 COMMISSION NO.SN:ZDN-DPL-013-2020
PTR NO.1945342,1/02/2020
IBP NO.095495,11/22/2019 for 2020
ATTORNEY’S ROLL NO. 65014
LAPU-LAPU ST. DIPOLOG CITY

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, JENNIFER ABESTROS ESTRADA, of legal age, Filipino, single, a resident of Quezon Ave., Centrial Brgy,
Dipolog City, Zamboanga del Norte after having been duly sworn in accordance with law, hereby
depose and state:

That I had possessed the Philhealth Identification card of John Gonzales Ke with No.14-050254976-2
because we have the same bookkeeper for the business.

That on August 18, 2020 at around 4 in the afternoon, while I was at the Dipolog City Bus Terminal I
checked my envelope I found out that the Philhealth ID of Mr. Ke was also lost, and could not be
found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said Philhealth ID.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2020, at
Dipolog City.

JENNIFER ABESTROS ESTRADA

(Affiant)
ID#______________________

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2020, at Dipolog City.

Doc. No.__
Page No.__
Book No.__
Series of 2020

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, DELIA A. CAMOTA, of legal age, Filipino, married, a resident of Victoria Homes, Obay,
Polanco, Zamboanga del Norte after having been duly sworn in accordance with law, hereby
depose and state:

That I am one of the compulsory heirs of Enecita Atab, registered owner of a parcel of land
covered by TCT No.T-3582,and I am sister of Nicolas Atab, registered owner of a land covered
by TCT No.T-3581 and of Alberto Atab, registered owner of parcel of land covered by TCT
No.T-3580 , all located at Magangon, Polanco, Zamboanga del Norte, all issued by Register of
Deeds for Zamboanga del Norte.

That sometime on January 12, 2019 my sister Leonida Atab Rebucas, who was the keeper of
land title certificates of our parents and siblings Alberto Atab and Nicolas Atab, died. Then I
checked from the husband of my sister Leonida regarding the documents and he informed me
that the certificates were lost, and could not be found;

That despite effort to recover the same but it was naught.

Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements
and for the purpose of attesting to the loss of the said Transfer Certificates of Title No.T-3582,
Transfer Certificates of Title No.T-3581, and Transfer Certificates of Title No.T-3580.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2020,
at Dipolog City.

DELIA A. CAMOTA

(Affiant)

OSCA ID#18-03396-Polanco,ZN

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2020, at Dipolog City.

Doc No. ____ IVO M. MANDANTES,CPA

Page No. __ NOTARY PUBLIC FOR ZAMBOANGA DELNORTE
Book No. __ VALID UNTIL 12-31-2021
Series of 2020 COMMISSION NO.SN:ZDN-DPL-013-2020
PTR NO.1945342,1/02/2020
IBP NO.095495,11/22/2019 for 2020
ATTORNEY’S ROLL NO. 65014
LAPU-LAPU ST. DIPOLOG CITY

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, JOSEPHINE M. BLEN, of legal age, Filipino, widow, a resident of Isis, Polanco, Zamboanga del Norte
after having been duly sworn in accordance with law, hereby depose and state:

That I am the holder and possessor of an original BIR Payment Slip for payment of Estate of Hedeliza
Maylon with Payment Slip Number 20800664 at Landbank issued by Bureau of Internal Revenue.

That I tried to locate the said BIR Payment Slip, I found out that said BIR Payment Slip was lost, and
could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said BIR Payment Slip.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2020, at
Dipolog City.

JOSEPHINE M. BLEN
(Affiant)
PPPP ID#097210012-0462-00021
With photo
SUBSCRIBED AND SWORN to before me this ___ day of _________ 2020, at Dipolog City.

Doc No. _____ IVO M. MANDANTES,CPA

Page No. _____ NOTARY PUBLIC FOR ZAMBOANGA DELNORTE
Book No. ____ VALID UNTIL 12-31-2021
Series of 2020 COMMISSION NO.SN:ZDN-DPL-013-2020
PTR NO.1945342,1/02/2020
IBP NO.095495,11/22/2019 for 2020
ATTORNEY’S ROLL NO. 65014
LAPU-LAPU ST. DIPOLOG CITY

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ANTON VAN R. LLIDO, of legal age, Filipino, single, a resident of Lalawan, Dicayas, Dipolog City,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of a Samsung Cellular phone with TM/Globe simcard Number
09067253342.

That August 15, 2020, I discovered that my said cellular phone was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said cellular phone with sim card and thereafter requesting
replacement of TM/Globe simcard.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2020, at
Dipolog City.

ANTON VAN R. LLIDO

(Affiant)
Driver’s License#J01-13-003576
SUBSCRIBED AND SWORN to before me this ___ day of _________ 2020, at Dipolog City.

Doc No. _____ IVO M. MANDANTES,CPA

Page No. _____ NOTARY PUBLIC FOR ZAMBOANGA DELNORTE
Book No. ____ VALID UNTIL 12-31-2021
Series of 2020 COMMISSION NO.SN:ZDN-DPL-013-2020
PTR NO.1945342,1/02/2020
IBP NO.095495,11/22/2019 for 2020
ATTORNEY’S ROLL NO. 65014
LAPU-LAPU ST. DIPOLOG CITY

Doc. No.__
Page No.__
Book No.__
Series of 2020
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, IVO MANDANTES of legal age, Filipino, married, a resident of Isis, Polanco,ZN after having been duly
sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of an original copy of Official Receipt No.1200569215 issued by LTO
for my vehicle with Plate No. DAE 9725.

That last week of July 2020, while I was trying to look for my said official receipt from my file folder,
then I found out that the Official receipt was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said LTO Official Receipt.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2020, at
Dipolog City.

IVO MANDANTES
(Affiant)
PRC ID#130282
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2020, at Dipolog City.

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x
 AFFIDAVIT OF LOSS

I, RODOLFO C. DALMAN of legal age, Filipino, married, a resident of Gen Luna St. Estaka, Dipolog City
after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of an original copy of e-Certificates Authorizing Registration(eCARs)

issued issued by Bureau of Internal Revenue with No. eCR201800001977 and eCR2018000019778 for
the estate taxes.

That last week of July 2020, while I was trying to look for my said eCARs from my file folder, then I
found out that the eCARs were lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said eCAR and reissuance of the same and claiming the
documents at the Bureau of Internal Revenue anent to the slip.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2020, at
Dipolog City.

RODOLFO C. DALMAN
(Affiant)
TIN#949-091-870
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2020, at Dipolog City.

Doc No. _____ IVO M. MANDANTES,CPA

Page No. _____ NOTARY PUBLIC FOR ZAMBOANGA DELNORTE
Book No. ____ VALID UNTIL 12-31-2021
Series of 2020 COMMISSION NO.SN:ZDN-DPL-013-2020
PTR NO.1945342,1/02/2020
IBP NO.095495,11/22/2019 for 2020
ATTORNEY’S ROLL NO. 65014
LAPU-LAPU ST. DIPOLOG CITY
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, JONATHAN U. GUTANG of legal age, Filipino, single, a resident of Estaka,Dipolog City after having
been duly sworn in accordance with law, hereby depose and state:

That I am attorney-in-fact of vendee Liberty Ombalino, a holder and possessor of original copy of
Deed of Absolute Sale notarized by Dario Mandantes per Doc.No. 1932, Page No.103. Book No.XV,
Series of 2017 with stamp at the back of the back of said document by BIR, Original copies of BIR Form
1706 and BIR Form 2000-DT, both with validated deposit slips from the bank and Original copy(Tax
payer’s Copy) of the BIR Form 2313-R all issued by Bureau of Internal Revenue.

That sometime July 2020, while I was trying to look for the said documents from file folder of the
vendee, then I found out that the said documents were lost, and could not be found. I asked the
vendee but she told me that the documents are all inside the folder ;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said documents and reissuance of the same and claiming
the documents at the Bureau of Internal Revenue.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2020, at
Dipolog City.

JONATHAN U. GUTANG
(Affiant)
DL#J01-17-004765
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2020, at Dipolog City.

Doc No. _____ IVO M. MANDANTES,CPA

Page No. _____ NOTARY PUBLIC FOR ZAMBOANGA DELNORTE
Book No. ____ VALID UNTIL 12-31-2021
Series of 2020 COMMISSION NO.SN:ZDN-DPL-013-2020
PTR NO.1945342,1/02/2020
IBP NO.095495,11/22/2019 for 2020
ATTORNEY’S ROLL NO. 65014
LAPU-LAPU ST. DIPOLOG CITY
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, GERMAN D. PILA, of legal age, Filipino, married, a resident of Gulayon, Dipolog City, Zamboanga del
Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of an Automated Teller Machine(ATM) cash card issued by Land
Bank of the Philippines(LBP)-Dipolog City Branch through DSWD.

That last week of this month, I discovered that the LBP ATM card was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said LBP ATM card and thereafter requesting replacement
thereon.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2020, at
Dipolog City.

GERMAN D.PILA
(Affiant)
ZN Provl Govt ID No.PGZN-4330493

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2020, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2020
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, DAYLINDA A. OCAMPO, of legal age, Filipino, married, a resident of Castillon Drive, Purok
Buli, Minaog, Dipolog City, Zamboanga del Norte after having been duly sworn in accordance
with law, hereby depose and state:

That I am a Secondary Teacher II employed by Department of Education.

That sometime in year 2014 I secured my Permit to Study issued by Office of Schools Division
Superintendent and I eventually studied my Doctoral Degree at Negros Oriental State
University. Then in July 2020 I checked file folder of documents where I always kept all
documents like employment records including the said Permit to Study covering first semester
of 2014-2015, but I found out that my Permit to Study was lost, and could not be found;

That despite effort to recover the same but it was naught.

Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements
and for the purpose of attesting to the loss of the said Permit to Study.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2020,
at Dipolog City.

DAYLINDA A. OCAMPO

(Affiant)

PRC ID#1257552-Professional Teacher

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2020, at Dipolog City.
Doc No. ____ IVO M. MANDANTES,CPA
Page No. __ NOTARY PUBLIC FOR ZAMBOANGA DELNORTE
Book No. __ VALID UNTIL 12-31-2021
Series of 2020 COMMISSION NO.SN:ZDN-DPL-013-2020
PTR NO.1945342,1/02/2020
IBP NO.095495,11/22/2019 for 2020
ATTORNEY’S ROLL NO. 65014
LAPU-LAPU ST. DIPOLOG CITY

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, VIRGINIA E. TAGAB, of legal age, Filipino, married, a resident of Sicayab, Dipolog City,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose
and state:

That I am an Assistant School Principal II employed by Department of Education.

That sometime in year 2018 I secured my Permit to Study issued by Office of Schools Division
Superintendent and I eventually studied my Doctorate Degree at Medina College Foundation
and again secured my Permit to Study for next semester and summer classes. Then early July
2020 I checked file folder of documents where I always kept all documents like employment
records including the said Permits to Study covering 2018-2019 regular semesters, 2019
summer class, 2019-2020 regular semesters, but I found out that my Permits to Study were
lost, and could not be found;

That despite effort to recover the same but it was naught.

Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements
and for the purpose of attesting to the loss of the said Permits to Study.

IN WITNESS WHEREOF, I have hereunto affixed my signature this 23rd day of July 2020, at
Dipolog City.

VIRGINIA E. TAGAB

(Affiant)

PRC ID#0447185-Professional Teacher

SUBSCRIBED AND SWORN to before me this 23rd day of July 2020, at Dipolog City.
Doc No.96 IVO M. MANDANTES,CPA
Page No. 21 NOTARY PUBLIC FOR ZAMBOANGA DELNORTE
Book No. 50\ VALID UNTIL 12-31-2021
Series of 2020 COMMISSION NO.SN:ZDN-DPL-013-2020
PTR NO.1945342,1/02/2020
IBP NO.095495,11/22/2019 for 2020
ATTORNEY’S ROLL NO. 65014
LAPU-LAPU ST. DIPOLOG CITY

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ROSINEE C. MONTE, of legal age, Filipino, married, a resident of Lower Dicayas, Dipolog City,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of a Unified Multi-purpose ID(UMID) card issued by GSIS.

That sometime 2nd week of July 2020, I lost my wallet which contained my said UMID card. I waited
for someone who might find it but nobody approached. Thus, I considered my said UMID card as lost,
and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said UMID ID card.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2020, at
Dipolog City.

ROSINEE C. MONTE
(Affiant)
ID#_______________________

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2020, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2020
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT

I, LOTHA S. LETEGIO of legal age, Filipino, a resident of Dawo, Dapitan City, Zamboanga del Norte after having
been duly sworn in accordance with law, hereby depose and state:

That I am attorney-in-fact of Ma.Gazelle Malacat and Ma.Sheila M. Aquino and I processed the payment of
estate taxes of their parents Amador Malacat and Lydia Eguia. That as a result, the BIR issued the following
eCARs:

a. eCR201300110690
b. eCR201300110692
c. eCR201600125302
d. eCR201300110686
e. eCR201300110691
f. eCR201300110688
g. eCR201300110693
h. eCR201300110689
i. eCR201300110687
j. eCR201300110685
k. eCR201700187901
l. eCR201600125307
m. eCR201600125301
n. eCR201700187904
o. eCR201600125304
p. eCR201700187903
q. eCR201700187902
r. eCR201600125305
s. eCR201600125306
t. eCR201600125300
u. eCR201600125303
v. eCR201600125308
That after I processed for the taxes in the name of my principals the Register of Deeds collected all the eCARs.
That however one of the properties was not transferred yet to the principal’s name because the property was
not yet titled at that time but covered only by tax declaration. That now the title was released under TCT No.T-
6436 but the eCARs was not available anymore because those were submitted to ROD already. The eCARs
were with reference no. eCR201300110690 and eCR201600125302.

That this is executed under oath and for purpose of reissuance of abovementioned eCARs.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2020, at Dipolog City.
LOTHA S. LETEGIO
(Attorney-in-Fact of MA. GAZELLE E. MALACAT &MA. SHEILA M. AQUINO per SPAs
attached)
Philhealth ID#14-2000918753-6
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2020, at Dipolog City.

Doc No. _____ IVO M. MANDANTES,CPA

Page No. _____ NOTARY PUBLIC FOR ZAMBOANGA DELNORTE
Book No. ____ VALID UNTIL 12-31-2021
Series of 2020 COMMISSION NO.SN:ZDN-DPL-013-2020
PTR NO.1945342,1/02/2020
IBP NO.095495,11/22/2019 for 2020
ATTORNEY’S ROLL NO. 65014
LAPU-LAPU ST. DIPOLOG CITY
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, JOEBERT R. LOCQUIAO, of legal age, Filipino, a resident of Sicayab, Dipolog City, Zamboanga
del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am an employee of the Provincial Government of Zamboanga del Norte.

That sometime July 2020, I tried to locate the Official Receipt issued by Provincial Treasurer’s
Office of Prov’l Gov’t of Zamboanga del Norte in favor of Endure Medical, Inc. with OR No.
7767013 in the amount of P6,348.22 as withholding tax. However, I found out that official
receipt was lost, and could not be found;

That despite effort to recover the same but it was naught.

Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements
and for the purpose of attesting to the loss of the said official receipt.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2020,
at Dipolog City.

JOEBERT R. LOCQUIAO

(Affiant)
 Provl Govt ZN-ZNMC ID#4330898

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2020, at Dipolog City.

Doc No. ____ IVO M. MANDANTES,CPA

Page No. __ NOTARY PUBLIC FOR ZAMBOANGA DELNORTE
Book No. __ VALID UNTIL 12-31-2021
Series of 2020 COMMISSION NO.SN:ZDN-DPL-013-2020
PTR NO.1945342,1/02/2020
IBP NO.095495,11/22/2019 for 2020
ATTORNEY’S ROLL NO. 65014
LAPU-LAPU ST. DIPOLOG CITY

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, CYRUS A. RATILLA, of legal age, Filipino, married, a resident of Sicayab, Dipolog City,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose
and state:

That I am a Teacher II employed by Department of Education.

That sometime in year 2014 I secured my Permit to Study issued by Office of Schools Division
Superintendent and I eventually studied my Masteral Degree at Jose Rizal Memorial State
University, Dapitan City. Then early 2020 I checked file folder of documents where I always
kept all documents like employment records including the said Permit to Study, I found out
that my Permit to Study was lost, and could not be found;

That despite effort to recover the same but it was naught.

Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements
and for the purpose of attesting to the loss of the said Permit to Study.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2020,
at Dipolog City.

CYRUS A. RATILLA

(Affiant)
 DL#J01-07-004604

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2020, at Dipolog City.

Doc No. ____ IVO M. MANDANTES,CPA

Page No. __ NOTARY PUBLIC FOR ZAMBOANGA DELNORTE
Book No. __ VALID UNTIL 12-31-2021
Series of 2020 COMMISSION NO.SN:ZDN-DPL-013-2020
PTR NO.1945342,1/02/2020
IBP NO.095495,11/22/2019 for 2020
ATTORNEY’S ROLL NO. 65014
LAPU-LAPU ST. DIPOLOG CITY

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, IRISH ORTEGA LAPONG, of legal age, Filipino, married, a resident of Sicayab, Dipolog City,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose
and state:

That I am one of the compulsory heirs of FRANCISCO ORTEGA, registered owner of a parcel of
land covered by OCT No. P-15649 located at Tamsi(now Letapan), Polanco, Zamboanga del
Norte.

That sometime in May 2018 my aunt Teofila Ortega Razo, who was the keeper of land title
certificates of her father Francisco, died. Then I checked file folder of documents where Teofila
always kept all documents like title of land, I found out that owner’s duplicate copy of the
above said title, together with other titles, was lost, and could not be found;

That despite effort to recover the same but it was naught.

Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements
and for the purpose of attesting to the loss of the said Original Certificate of Title No.P-15649.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2020,
at Dipolog City.

IRISH ORTEGA LAPONG

(Affiant)

DL#J01-18-002856

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2020, at Dipolog City.
Doc No. ____ IVO M. MANDANTES,CPA
Page No. __ NOTARY PUBLIC FOR ZAMBOANGA DELNORTE
Book No. __ VALID UNTIL 12-31-2021
Series of 2020 COMMISSION NO.SN:ZDN-DPL-013-2020
PTR NO.1945342,1/02/2020
IBP NO.095495,11/22/2019 for 2020
ATTORNEY’S ROLL NO. 65014
LAPU-LAPU ST. DIPOLOG CITY

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, MARIA FE C. BALLADARES, of legal age, Filipino, single, a resident of Barra, Dipolog City, Zamboanga
del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of a Official Receipt/Certificate of Registration for Motor Vehicle
issued by LTO, with Plate No. 2238 JR, Make:Honda;

That last week of May 28, 2020, I tried to locate the OR/certificate of registration from the folder
where I kept all of my important documents and other claims but it was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said OR/CR.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2020, at
Dipolog City.

MARIA FE C. BALLADARES
(Affiant)
DL#J01-07-003040

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2020, at Dipolog City.

Doc No. _____ IVO M. MANDANTES,CPA

Page No. _____ NOTARY PUBLIC FOR ZAMBOANGA DELNORTE
Book No. ____ VALID UNTIL 12-31-2021
Series of 2020 COMMISSION NO.SN:ZDN-DPL-013-2020
PTR NO.1945342,1/02/2020
IBP NO.095495,11/22/2019 for 2020
ATTORNEY’S ROLL NO. 65014
LAPU-LAPU ST. DIPOLOG CITY
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, DANILO SUMILANG, of legal age, Filipino, married, a resident of Gulayon,

Dipolog City, Zamboanga del Norte, after having been duly sworn in
accordance with law, hereby depose and state:

That I am a holder and possessor of an official receipt(OR) with No. 7766783

dated June 23, 2020 issued by LGU-Zamboanga del Norte because I
processed for the transfer of title involving TCT No.T-62794;

That on the same, while I was trying to look for the said OR from the file
folder where I kept it, I found out that the OR was lost, and could not be
found;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost;

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

foregoing statements and for the purpose of attesting to the loss of the said
OR.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2020, at Dipolog City.

DANILO SUMILANG
(Affiant)
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2020, at

Dipolog City.

Doc No. _____ IVO M. MANDANTES,CPA

Page No. _____ NOTARY PUBLIC FOR ZAMBOANGA DELNORTE
Book No. ____ VALID UNTIL 12-31-2021
Series of 2020 COMMISSION NO.SN:ZDN-DPL-013-2020
PTR NO.1945342,1/02/2020
IBP NO.095495,11/22/2019 for 2020
ATTORNEY’S ROLL NO. 65014
 LAPU-LAPU ST. DIPOLOG CITY

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ESTRELLITA B. ANGUILID, of legal age, Filipino, married, a resident of

Sicayab, Dipolog City, Zamboanga del Norte, after having been duly sworn
in accordance with law, hereby depose and state:

That I am a holder and possessor of a Passbook with Account No. 001-10-

0033581 issued by PBCOM-Dipolog City Branch under the name of Ranulfo
Suarez and Estrellita Anguilid;

That on March, 2020, while I was trying to look for the said passbook from
my bag I kept it, I found out that the passbook was lost, and could not be
found;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost;

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

foregoing statements and for the purpose of attesting to the loss of the said
Passbook issued by PBCOM-Dipolog City Branch.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2020, at Dipolog City.

ESTRELLITA B. ANGUILID
(Affiant)
OSCA ID#9290-Dipolog City
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2020, at

Dipolog City.

Doc No. _____ IVO M. MANDANTES,CPA

Page No. _____ NOTARY PUBLIC FOR ZAMBOANGA DELNORTE
Book No. ____ VALID UNTIL 12-31-2021
Series of 2020 COMMISSION NO.SN:ZDN-DPL-013-2020
PTR NO.1945342,1/02/2020
IBP NO.095495,11/22/2019 for 2020
ATTORNEY’S ROLL NO. 65014
LAPU-LAPU ST. DIPOLOG CITY
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, JAMES S. GOZO, of legal age, Filipino, married, a resident of Purok Bayanihan, Sta. Filomena,
Dipolog City, Zamboanga del Norte after having been duly sworn in accordance with law,
hereby depose and state:

That I am a holder/possessor of Driver’s License issued by Land Transportation Office;

That on June 15, 2020, while I was trying to locate the said Driver’s License I could not find it
because my wallet was lost and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements
and for the purpose of attesting to the loss of the said Driver’s License ID card.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2020,
at Dipolog City.

JAMES S. GOZO
(Affiant)
VIN#7202-0227B-H3084JSG10000-0

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2020, at Dipolog City.

Doc No. _____ IVO M. MANDANTES,CPA

Page No. _____ NOTARY PUBLIC FOR ZAMBOANGA DELNORTE
Book No. ____ VALID UNTIL 12-31-2021
Series of 2020 COMMISSION NO.SN:ZDN-DPL-013-2020
PTR NO.1945342,1/02/2020
IBP NO.095495,11/22/2019 for 2020
ATTORNEY’S ROLL NO. 65014
LAPU-LAPU ST. DIPOLOG CITY
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, MARCELA BANAS-NALZARO, of legal age, Filipino, widow, a resident of Sta.Filomena,

DIpolog City after having been duly sworn in accordance with law, hereby depose and state:

That I am the surviving spouse of Lucio Nalzaro, registered owner of a parcel of land known as
Lot 1419-C-9 , located at Sta. Filomena, Dipolog City, covered by Transfer Certificate of Title
No.(T-25751)4662 issued by Register of Deeds for Dipolog City.

That on April 17, 2018, my house, where I kept certificates of title and other important
documents of my late spouse and also my properties including the abovesaid certificate of
title, was accidentally burned down.

That despite effort to recover the same during such incident but it was naught.

Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements
and for the purpose of attesting to the loss of the said Transfer Certificate of Title No.(T-
25751)4662.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2020,
at Dipolog City.

MARCELA BANAS-NALZARO

(Affiant)

ID#__________________________

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2020, at Dipolog City.

Doc No. ____ IVO M. MANDANTES,CPA

Page No. __ NOTARY PUBLIC FOR ZAMBOANGA DELNORTE
Book No. __ VALID UNTIL 12-31-2021
Series of 2020 COMMISSION NO.SN:ZDN-DPL-013-2020
PTR NO.1945342,1/02/2020
IBP NO.095495,11/22/2019 for 2020
ATTORNEY’S ROLL NO. 65014
LAPU-LAPU ST. DIPOLOG CITY
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, REMELY GACUMA CACHIN, of legal age, Filipino, a resident of Purok 2, Sta. Isabel, Dipolog
City, Zamboanga del Norte after having been duly sworn in accordance with law, hereby
depose and state:

That I am a holder/possessor of Social Security System(SSS) ID issued by SSS and Driver’s

License issued by Land Transportation Office(LTO);

That sometime year 2019, while I was trying to locate the my said LTO ID &SSS ID I could not
find it because it was lost and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements
and for the purpose of attesting to the loss of the said ID cards.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2020,
at Dipolog City.

REMELY GACUMA CACHIN

(Affiant)
SSS ID#10-0586419-8

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2020, at Dipolog City.

Doc No. _____ IVO M. MANDANTES,CPA

Page No. _____ NOTARY PUBLIC FOR ZAMBOANGA DELNORTE
Book No. ____ VALID UNTIL 12-31-2021
Series of 2020 COMMISSION NO.SN:ZDN-DPL-013-2020
PTR NO.1945342,1/02/2020
IBP NO.095495,11/22/2019 for 2020
ATTORNEY’S ROLL NO. 65014
LAPU-LAPU ST. DIPOLOG CITY
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, RESART JON F. SACATROPEZ, of legal age, Filipino, married, a resident of Purok Bougainvilla,
Sta. Filomena, Dipolog City, Zamboanga del Norte after having been duly sworn in accordance
with law, hereby depose and state:

That I am a holder/possessor of Driver’s License issued by Land Transportation Office;

That on June 15, 2020, while I was trying to locate the said Driver’s License I could not find it
because it was lost and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements
and for the purpose of attesting to the loss of the said Driver’s License ID card.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2020,
at Dipolog City.

RESART JON F. SACATROPEZ

(Affiant)
Pag-ibig MID#1210-9365-4034

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2020, at Dipolog City.

Doc No. _____ IVO M. MANDANTES,CPA

Page No. _____ NOTARY PUBLIC FOR ZAMBOANGA DELNORTE
Book No. ____ VALID UNTIL 12-31-2021
Series of 2020 COMMISSION NO.SN:ZDN-DPL-013-2020
PTR NO.1945342,1/02/2020
IBP NO.095495,11/22/2019 for 2020
ATTORNEY’S ROLL NO. 65014
LAPU-LAPU ST. DIPOLOG CITY
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, EMELIA LLORENTE GOMOLON of legal age, Filipino, a resident of Isis, Polanco, Zamboanga del Norte
after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of original Certificate Authorizing Registration(CAR),& Estate Tax
Return & other related documents issued by Bureau of Internal Revenue for estate of Amando Alos
Llorente processed and paid in year 2005 which was processed manually.

That recently, while I was trying to look for my said original documents/stub from my file folder, then
I found out that original documents in my possession were lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said documents and reissuance of the same and claiming
the documents at the Bureau of Internal Revenue anent to the same in electronic manner because it
was recorded and processed manually.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2020, at
Dipolog City.

EMELIA LLORENTE GOMOLON

(Affiant)
TIN#290-265-574
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2020, at Dipolog City.

Doc No. _____ IVO M. MANDANTES,CPA

Page No. _____ NOTARY PUBLIC FOR ZAMBOANGA DELNORTE
Book No. ____ VALID UNTIL 12-31-2021
Series of 2020 COMMISSION NO.SN:ZDN-DPL-013-2020
PTR NO.1945342,1/02/2020
IBP NO.095495,11/22/2019 for 2020
ATTORNEY’S ROLL NO. 65014
LAPU-LAPU ST. DIPOLOG CITY
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, JEOANN V. ABIAN, of legal age, Filipino, married, a resident of Isis, Polanco, Zamboanga del Norte
after having been duly sworn in accordance with law, hereby depose and state:

That I am a graduate of Bachelor of Science in Education at Jose Rizal Memorial State University(then
Jose Rizal Memorial State College), Dipolog City Campus in year 2008. I was a holder and possessor of
a Diploma issued by said university.

That in the first week of June, 2020, while I was trying to locate the said diploma, but it was lost and
could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said Diploma.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2020, at
Dipolog City.

JEOANN V. ABIAN
(Affiant)
Pag-ibig MID#1211-1585-6947

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2020, at Dipolog City.

Doc No. _____ IVO M. MANDANTES,CPA

Page No. _____ NOTARY PUBLIC FOR ZAMBOANGA DELNORTE
Book No. ____ VALID UNTIL 12-31-2021
Series of 2020 COMMISSION NO.SN:ZDN-DPL-013-2020
PTR NO.1945342,1/02/2020
IBP NO.095495,11/22/2019 for 2020
ATTORNEY’S ROLL NO. 65014
LAPU-LAPU ST. DIPOLOG CITY
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, LIBRADA D. BELTRAN, of legal age, Filipino, widow, a resident of Isis, Polanco, Zamboanga del Norte
after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of OSCA(Senior Citizen’s) Identification Card.

That sometime second week of May, 2020, while I was going to my house I passed through the river
and all my documents fell out, I found out that my OSCA ID was also lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said OSCA ID.

IN WITNESS WHEREOF, I have hereunto affixed my signature this 10th day of June 2020, at Dipolog
City.

LIBRADA D. BELTRAN
(Affiant)
Philhealth ID#14-250180490-7

SUBSCRIBED AND SWORN to before me this 10th day of June 2020, at Dipolog City.

Doc No. 4981 IVO M. MANDANTES,CPA

Page No. 35 NOTARY PUBLIC FOR ZAMBOANGA DELNORTE
Book No. 46 VALID UNTIL 12-31-2021
Series of 2020 COMMISSION NO.SN:ZDN-DPL-013-2020
PTR NO.1945342,1/02/2020
IBP NO.095495,11/22/2019 for 2020
ATTORNEY’S ROLL NO. 65014
LAPU-LAPU ST. DIPOLOG CITY
Doc. No.__
Page No.__
Book No.__
Series of 2020

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, AISA M. YORONG, of legal age, Filipino, married, a resident of Gulayon, DIpolog City,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose
and state:

That I am a holder/possessor of receipt of pawned jewelry issued by Cebuana Lhuillier

Pawnshop;

That sometime May, 2020, while I was trying to locate the said receipt I could not find it
because it was lost and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;
As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements
and for the purpose of attesting to the loss of the said receipt.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2020,
at Dipolog City.

AISA M. YORONG
(Affiant)
TIN#361-430-527

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2020, at Dipolog City.

Doc No. _____ IVO M. MANDANTES,CPA

Page No. _____ NOTARY PUBLIC FOR ZAMBOANGA DELNORTE
Book No. ____ VALID UNTIL 12-31-2021
Series of 2020 COMMISSION NO.SN:ZDN-DPL-013-2020
PTR NO.1945342,1/02/2020
IBP NO.095495,11/22/2019 for 2020
ATTORNEY’S ROLL NO. 65014
LAPU-LAPU ST. DIPOLOG CITY

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ELMIRA V. REDILLAS, of legal age, Filipino, a resident of Obay, Polanco, Zamboanga del Norte
after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder/possessor of SSS ID issued by SSS;

That sometime first week of June, 2020, while I was trying to locate the said SSS ID I could not
find it because it was lost and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;
As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements
and for the purpose of attesting to the loss of the said ID card.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2020,
at Dipolog City.

ELMIRA V. REDILLAS
(Affiant)
SSS ID#33-9607587-2

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2020, at Dipolog City.

Doc No. _____ IVO M. MANDANTES,CPA

Page No. _____ NOTARY PUBLIC FOR ZAMBOANGA DELNORTE
Book No. ____ VALID UNTIL 12-31-2021
Series of 2020 COMMISSION NO.SN:ZDN-DPL-013-2020
PTR NO.1945342,1/02/2020
IBP NO.095495,11/22/2019 for 2020
ATTORNEY’S ROLL NO. 65014
LAPU-LAPU ST. DIPOLOG CITY

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ARNOLD PAMAGAN, of legal age, Filipino, a resident of Obay, Polanco, Zamboanga del Norte
after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder/possessor of Driver’s License issued by LTO and Voters ID issued by

COMELEC;

That sometime first week of June, 2020, while I was trying to locate the said Driver’s License
and COMELEC ID I could not find it because it was lost and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements
and for the purpose of attesting to the loss of the said ID cards.
IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2020,
at Dipolog City.

ARNOLD PAMAGAN
(Affiant)
ID#___________________

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2020, at Dipolog City.

Doc No. _____ IVO M. MANDANTES,CPA

Page No. _____ NOTARY PUBLIC FOR ZAMBOANGA DELNORTE
Book No. ____ VALID UNTIL 12-31-2021
Series of 2020 COMMISSION NO.SN:ZDN-DPL-013-2020
PTR NO.1945342,1/02/2020
IBP NO.095495,11/22/2019 for 2020
ATTORNEY’S ROLL NO. 65014
LAPU-LAPU ST. DIPOLOG CITY

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, JOSE L. BARILLOS, of legal age, Filipino, a resident of Turno, Dipolog City, Zamboanga del Norte after
having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of OSCA(Senior Citizen’s) Identification Card.

That sometime second week of May, 2020, while I was checking my bag I found out that my OSCA ID
was also lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said OSCA ID.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2020, at
Dipolog City.
 JOSE L. BARILLOS
(Affiant)
ID#______________________

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2020, at Dipolog City.

Doc. No.__
Page No.__
Book No.__
Series of 2020

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, PINKY O. MANCAO, of legal age, Filipino, single, a resident of Nangca, Rizal, Zamboanga del
Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder of two(2) Receipts issued by ML Lhuillier Pawnshop at Polanco, ZN Branch

for Pawned Jewelry namely pendant and necklace and LTO Student Permit(SP).
That sometime March, 2020, while I was trying to locate the said receipts and SP card, but it
was lost and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements
and for the purpose of attesting to the loss of the said receipts and SP card.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2020,
at Dipolog City.

PINKY O. MANCAO
(Affiant)
Philhealth ID#14-025309527-6

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2020, at Dipolog City.

Doc No. _____ IVO M. MANDANTES,CPA

Page No. _____ NOTARY PUBLIC FOR ZAMBOANGA DELNORTE
Book No. ____ VALID UNTIL 12-31-2021
Series of 2020 COMMISSION NO.SN:ZDN-DPL-013-2020
PTR NO.1945342,1/02/2020
IBP NO.095495,11/22/2019 for 2020
ATTORNEY’S ROLL NO. 65014
LAPU-LAPU ST. DIPOLOG CITY

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, EVA O. SALONOY, of legal age, Filipino, married, a resident of Pob.North, Polanco,

Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose
and state:
That I am one of the children/compulsory heirs of Bienvenido Ocupe, married to Gonzala
Dalman, registered owner of a parcel of land covered by OCT No. O-61 located at Guinles(now
Poblacion North), Polanco, Zamboanga del Norte.

That sometime in January 2019 my brother Orlando Ocupe, who was the keeper of land title
certificates of our father, died. Then I checked file folder of documents where Orlando always
kept all documents like title of land, I found out that owner’s duplicate copy of the above said
title, together with other titles, was lost, and could not be found;

That despite effort to recover the same but it was naught.

Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements
and for the purpose of attesting to the loss of the said Original Certificate of Title No.O-61.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2020,
at Dipolog City.

EVA O. SALONOY

(Affiant)

OSCA ID#18-03992-Polanco, Zamboanga del Norte

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2020, at Dipolog City.

Doc No. ____ IVO M. MANDANTES,CPA

Page No. __ NOTARY PUBLIC FOR ZAMBOANGA DELNORTE
Book No. __ VALID UNTIL 12-31-2021
Series of 2020 COMMISSION NO.SN:ZDN-DPL-013-2020
PTR NO.1945342,1/02/2020
IBP NO.095495,11/22/2019 for 2020
ATTORNEY’S ROLL NO. 65014
LAPU-LAPU ST. DIPOLOG CITY

Doc. No.__
Page No.__
Book No.__
Series of 2019
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ANTONIETA TAWAT ACASO, of legal age, Filipino, widow, a resident of Magangon, Polanco,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of OSCA(Senior Citizen’s) Identification Card.

That sometime second week of May, 2020, while I was going to my house I passed through the river
and all my documents fell out, I found out that my OSCA ID was also lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said OSCA ID.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2020, at
Dipolog City.

ANTONIETA TAWAT ACASO

(Affiant)
ID#______________________

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2020, at Dipolog City.

Doc. No.__
Page No.__
Book No.__
Series of 2020
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, JADE S. ACOJEDO, minor, Filipino, a resident of Polanco, Zamboanga del Norte assisted by
Arlene V. Sandueta, after having been duly sworn in accordance with law, hereby depose and
state:

That I am a holder of PPPP Identification card issued by DSWD.

That sometime first week of May, 2020, while I was trying to locate the said identification card
from the file I usually kept it, but it was lost and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements
and for the purpose of attesting to the loss of the said identification card.

IN WITNESS WHEREOF, I have hereunto affixed my signature this 14th day of May 2020, at
Dipolog City.

JADE S. ACOJEDO
(Affiant)
ID#_____________________

SUBSCRIBED AND SWORN to before me this 14th day of May 2020, at Dipolog City.

Doc No. 2359 IVO M. MANDANTES,CPA

Page No. 152 NOTARY PUBLIC FOR ZAMBOANGA DELNORTE
Book No. 44 VALID UNTIL 12-31-2021
Series of 2020 COMMISSION NO.SN:ZDN-DPL-013-2020
PTR NO.1945342,1/02/2020
IBP NO.095495,11/22/2019 for 2020
ATTORNEY’S ROLL NO. 65014
LAPU-LAPU ST. DIPOLOG CITY
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ELEAZAR B. BALANGITAO, of legal age, Filipino, a resident of Purok 3 Poblacion, Sibutad,

Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose
and state:

That I am a holder of Receipt No. 0063-2020-00085 issued by ML Lhuillier re: Pawned

Jewelry/ies.

That in the first week of March, 2020, while I was trying to locate the said receipt, but it was
lost and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements
and for the purpose of attesting to the loss of the said receipt.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2020,
at Dipolog City.

ELEAZAR B. BALANGITAO
(Affiant)
 ID#_________________________

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2020, at Dipolog City.

Doc No. _____ IVO M. MANDANTES,CPA

Page No. _____ NOTARY PUBLIC FOR ZAMBOANGA DELNORTE
Book No. ____ VALID UNTIL 12-31-2021
Series of 2020 COMMISSION NO.SN:ZDN-DPL-013-2020
PTR NO.1945342,1/02/2020
IBP NO.095495,11/22/2019 for 2020
ATTORNEY’S ROLL NO. 65014
LAPU-LAPU ST. DIPOLOG CITY

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, JAYSON BANAD ELIAZAR, of legal age, Filipino, single, a resident of Monkayo, Compostela Valley
after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of a driver’s license issued by the Land Transportation Office.

That on March 11, 2020, while I was trying to locate the said driver’s license I found out my wallet
containing the said license was lost and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said driver’s license.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2020, at
Dipolog City.

JAYSON BANAD ELIAZAR

(Affiant)
ID#____________________

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2020, at Dipolog City.
Doc No. _____ IVO M. MANDANTES,CPA
Page No. _____ NOTARY PUBLIC FOR ZAMBOANGA DELNORTE
Book No. ____ VALID UNTIL 12-31-2021
Series of 2020 COMMISSION NO.SN:ZDN-DPL-013-2020
PTR NO.1945342,1/02/2020
IBP NO.095495,11/22/2019 for 2020
ATTORNEY’S ROLL NO. 65014
LAPU-LAPU ST. DIPOLOG CITY

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, GLORIA D. CUBALAN, of legal age, Filipino, married, a resident of Gulayon, Dipolog City, Zamboanga
del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am the mother of ADRIAN IAN D. CUBALAN, a graduate at JRMSC High School, Dipolog City in
year 2014. He was a holder and possessor of a High Diploma issued by JRMSC.

That in the first week of March, 2020, while I was trying to locate the said diploma because my child
would use it for visa application abroad I found out it was lost and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said Diploma.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2020, at
Dipolog City.

GLORIA D. CUBALAN
(Affiant)
UMID#CRN-006-0126-9544-9

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2020, at Dipolog City.

Doc No. _____ IVO M. MANDANTES,CPA

Page No. _____ NOTARY PUBLIC FOR ZAMBOANGA DELNORTE
Book No. ____ VALID UNTIL 12-31-2021
Series of 2020 COMMISSION NO.SN:ZDN-DPL-013-2020
PTR NO.1945342,1/02/2020
IBP NO.095495,11/22/2019 for 2020
ATTORNEY’S ROLL NO. 65014
LAPU-LAPU ST. DIPOLOG CITY

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, JOGRACE E. REGENCIA, of legal age, Filipino, married to Val Angelo D. Regencia, a resident of
Sta. Isabel Dipolog City after having been duly sworn in accordance with law, hereby depose
and state:

That I am the buyer of a parcel of land known as Lot 12-C-1 covered by TCT No. T-14901
situated at Sta. Isabel, Dipolog City.

That when I purchased the said parcel of land the seller Joy Gomez endorsed to me a
photocopy of the Deed of Sale executed by Joel D. Elia as vendor notarized by Claver Pajaren
per Doc No. 4234, Page No. 16, Book No. XXIII, Series of 2011. She did not give me an original
copy of the Deed of Sale but only a certified copy from the notary public. I tried to collect an
original copy of said deed with stamp of BIR from vendor Joy Gomez but it was lost and could
not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements
and for the purpose of attesting to the loss of the said original copy of Deed of Absolute Sale
with BIR stamp.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2020,
at Dipolog City.

JOGRACE E. REGENCIA
 (Affiant)
DL#J01-14-001712 valid until 2/27/23

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2020, at Dipolog City.

Doc No. _____ IVO M. MANDANTES,CPA

Page No. _____ NOTARY PUBLIC FOR ZN,CITIES OF DIPOLOG/DAPITAN
Book No. ____ VALID UNTIL 12-31-2021
Series of 2020 COMMISSION NO.SN:ZDN-DPL-013-2020
PTR NO.1945342,1/02/2020-Dipolog City
IBP NO.095495,11/22/2019 for CY2020
ATTORNEY’S ROLL NO. 65014
LAPU-LAPU ST. ESTAKA,DIPOLOG CITY

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF NON-LOSS

I, JOGRACE E. REGENCIA, of legal age, Filipino, married to Val Angelo D. Regencia, a resident of
Sta. Isabel Dipolog City after having been duly sworn in accordance with law, hereby depose
and state:

That I am the buyer of a parcel of land known as Lot 12-C-1 covered by TCT No. T-14901
situated at Sta. Isabel, Dipolog City.

That the owner’s duplicate copy of the said parcel of land was declared as lost by previous
owner Joy Gomez but after further checking and inspection, it was found that the owner’s
duplicate copy was already endorsed to me prior to the execution of the Deed of Sale.

As such, I am executing this Affidavit of Non-Loss to attest to the truth of the foregoing
statements and for the purpose of annotating this document before the Register of Deeds of
Dipolog City and certifying the non-loss of said certificate of title.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2020,
at Dipolog City.

JOGRACE E. REGENCIA
 (Affiant)
DL#J01-14-001712 valid until 2/27/23

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2020, at Dipolog City.

Doc No. _____ IVO M. MANDANTES,CPA

Page No. _____ NOTARY PUBLIC FOR ZN,CITIES OF DIPOLOG/DAPITAN
Book No. ____ VALID UNTIL 12-31-2021
Series of 2020 COMMISSION NO.SN:ZDN-DPL-013-2020
PTR NO.1945342,1/02/2020-Dipolog City
IBP NO.095495,11/22/2019 for CY2020
ATTORNEY’S ROLL NO. 65014
LAPU-LAPU ST. ESTAKA,DIPOLOG CITY

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, MAEDEN V. FLOGIO, minor, Filipino, a resident of Dipolog City, Zamboanga del Norte assisted
by Arlene V. Sandueta, after having been duly sworn in accordance with law, hereby depose
and state:

That I am a holder of my mother’s PPPP Identification card named Ma. Shiela J. VIllanos, who
went abroad for work and left me her Identification card. The Identification card Number is
097202006-8217-00005.

That sometime March, 2020, while I was trying to locate the said identification card, but it was
lost and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements
and for the purpose of attesting to the loss of the said identification card.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2020,
at Dipolog City.

MAEDEN V. FLOGIO
(Affiant)
ZNNHS LRN:125966110016
 Assisted by:

ARLENE V. SANDUETA

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2020, at Dipolog City.

Doc No. _____ IVO M. MANDANTES,CPA

Page No. _____ NOTARY PUBLIC FOR ZAMBOANGA DELNORTE
Book No. ____ VALID UNTIL 12-31-2021
Series of 2020 COMMISSION NO.SN:ZDN-DPL-013-2020
PTR NO.1945342,1/02/2020
IBP NO.095495,11/22/2019 for 2020
ATTORNEY’S ROLL NO. 65014
LAPU-LAPU ST. DIPOLOG CITY

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, MA EVA E. AVILA, of legal age, Filipino, a resident of Dipolog City, Zamboanga del Norte after
having been duly sworn in accordance with law, hereby depose and state:

That I am a holder of Receipt issued by Palawan Pawnshop at Dipolog Rotunda Branch, Dipolog
City for Pawned Jewelry.

That sometime December, 2019, while I was trying to locate the said receipt, but it was lost
and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements
and for the purpose of attesting to the loss of the said receipt.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2020,
at Dipolog City.

MA. EVA E. AVILA

(Affiant)
 PRC ID#0018556- Social Worker

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2020, at Dipolog City.

Doc No. _____ IVO M. MANDANTES,CPA

Page No. _____ NOTARY PUBLIC FOR ZAMBOANGA DELNORTE
Book No. ____ VALID UNTIL 12-31-2021
Series of 2020 COMMISSION NO.SN:ZDN-DPL-013-2020
PTR NO.1945342,1/02/2020
IBP NO.095495,11/22/2019 for 2020
ATTORNEY’S ROLL NO. 65014
LAPU-LAPU ST. DIPOLOG CITY

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, NELSON C. GONZALES, of legal age, Filipino, a resident of Sta. Isabel, Dipolog City, Zamboanga del
Norte after having been duly sworn in accordance with law, hereby depose and state:

That I was a holder and possessor of a receipt with Control No. 70019 and Ticket No. 60859 for
Cellular Phone pawned which is more particularly described as “VEVO 1801 S#8674020 48015390,
8GB Memory Card;

That on March 4, 2020, I tried to locate the receipt from my wallet where I kept all of my important
documents but it was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said receipt.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2020, at
Dipolog City.

NELSON C. GONZALES
(Affiant)
PNP ID#18D230016
SUBSCRIBED AND SWORN to before me this ___ day of _________ 2020, at Dipolog City.

Doc No. _____ IVO M. MANDANTES,CPA

Page No. _____ NOTARY PUBLIC FOR ZAMBOANGA DELNORTE
Book No. ____ VALID UNTIL 12-31-2021
Series of 2020 COMMISSION NO.SN:ZDN-DPL-013-2020
PTR NO.1945342,1/02/2020
IBP NO.095495,11/22/2019 for 2020
ATTORNEY’S ROLL NO. 65014
LAPU-LAPU ST. DIPOLOG CITY

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, JANEFER C. ESIC, of legal age, Filipino, single, a resident of Purok D’Beach, Sicayab, Dipolog City,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of an Official Receipt(OR) with No. 7752917 issued by Province of
Zamboanga del Norte- ZNMC with the amount of P12,105.00 for medicines purchased on March 1,
2020;

That on the same date, I tried to locate the OR from my wallet where I kept all of my important
documents but it was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said OR.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2020, at
Dipolog City.

JANEFER C. ESIC
(Affiant)
PRC ID#0441583 valid until 11/25/2022

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2020, at Dipolog City.
Doc No. _____ IVO M. MANDANTES,CPA
Page No. _____ NOTARY PUBLIC FOR ZAMBOANGA DELNORTE
Book No. ____ VALID UNTIL 12-31-2021
Series of 2020 COMMISSION NO.SN:ZDN-DPL-013-2020
PTR NO.1945342,1/02/2020
IBP NO.095495,11/22/2019 for 2020
ATTORNEY’S ROLL NO. 65014
LAPU-LAPU ST. DIPOLOG CITY

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, JYN CAMATURA COLOT, of legal age, Filipino, a resident of Olingan, DIpolog City, Zamboanga del
Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of Social Security System(SSS) Identification Card(ID).

That on March 10, 2019 while I was trying to locate my SSS ID from my file I found out that my SSS ID
was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said SSS ID.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2020, at
Dipolog City.

JYN CAMATURA COLOT

(Affiant)
SSS#1006954188
SUBSCRIBED AND SWORN to before me this ___ day of _________ 2020, at Dipolog City.

Doc No. _____ IVO M. MANDANTES,CPA

Page No. _____ NOTARY PUBLIC FOR ZAMBOANGA DELNORTE
Book No. ____ VALID UNTIL 12-31-2021
Series of 2020 COMMISSION NO.SN:ZDN-DPL-013-2020
PTR NO.1945342,1/02/2020
IBP NO.095495,11/22/2019 for 2020
ATTORNEY’S ROLL NO. 65014
LAPU-LAPU ST. DIPOLOG CITY

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

SWORN STATEMENT

I, ABDUL MINDOON LUMBOS, of legal age, Filipino, married, a resident of Gil Sanchez, Labason,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a retired member of Philippine National Police.

That I am currently processing my clearance for my retirement benefits and I had turned-in the
service firearm issued to my name, which is more particularly described as follows:

“PISTOL COLT with Serial Number 142107.”

That the said firearm was turned-in without alteration or modification or changes and I was
subsequently issued a Property Turn-in Slip by the Logistic Support Service.
That the firearm is its original state and in good condition when returned to the Philippine National
Police.

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

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2020, at
Dipolog City.

ABDUL MINDOON LUMBOS

(Affiant)
PNP ID#18D110382
Expiry Date: 8/23/2021

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2020, at Dipolog City.

Doc No. _____ IVO M. MANDANTES,CPA

Page No. _____ NOTARY PUBLIC FOR ZN,CITIES OF DIPOLOG/DAPITAN
Book No. ____ VALID UNTIL 12-31-2021
Series of 2020 COMMISSION NO.SN:ZDN-DPL-013-2020
PTR NO.1945342,1/02/2020-Dipolog City
IBP NO.095495,11/22/2019 for CY2020
ATTORNEY’S ROLL NO. 65014
LAPU-LAPU ST. ESTAKA,DIPOLOG CITY
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, MELANIE E. BAGSICAN, of legal age, Filipino, married, a resident of Purok Aguinaldo, Pob. South,
Polanco, Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose
and state:

That I am a holder and possessor of a Philippine Passport issued by the Department of Foreign Affairs.

That sometime in November 2017, our barangay suffered flashflood and during such flashflood my
personal belongings including my passport was washed away;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said passport.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2020, at
Dipolog City.

MELANIE E. BAGSICAN
(Affiant)
Voter’s ID#7210-0008B-J1989MBD20000-5

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2020, at Dipolog City.

Doc No. _____ IVO M. MANDANTES,CPA

Page No. _____ NOTARY PUBLIC FOR ZN,CITIES OF DIPOLOG/DAPITAN
Book No. ____ VALID UNTIL 12-31-2021
Series of 2020 COMMISSION NO.SN:ZDN-DPL-013-2020
PTR NO.1945342,1/02/2020-Dipolog City
IBP NO.095495,11/22/2019 for CY2020
ATTORNEY’S ROLL NO. 65014
LAPU-LAPU ST. ESTAKA,DIPOLOG CITY
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, REYNALDO T. GENOBATEN of legal age, Filipino, married, a resident of Poblacion, Katipunan,

Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of a slip of BIR Claim Slip#0215 issued on September 30, 2019 issued
by Bureau of Internal Revenue for eCAR of estate tax.

That on the same date, while I was trying to look for my said claim stub from my file folder, then I
found out that my claim slip was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said claim slip and reissuance of the same and claiming the
documents at the Bureau of Internal Revenue anent to the slip.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2020, at
Dipolog City.

REYNALDO T. GENOBATEN
(Affiant)
Driver’s License#J01-77-008627
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2020, at Dipolog City.

Doc No. _____ IVO M. MANDANTES,CPA

Page No. _____ NOTARY PUBLIC FOR ZAMBOANGA DELNORTE
Book No. ____ VALID UNTIL 12-31-2021
Series of 2020 COMMISSION NO.SN:ZDN-DPL-013-2020
PTR NO.1945342,1/02/2020
IBP NO.095495,11/22/2019 for 2020
ATTORNEY’S ROLL NO. 65014
LAPU-LAPU ST. DIPOLOG CITY
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, GINA H. DAYMIEL, of legal age, Filipino, married, a resident of Turno, Dipolog City, Zamboanga del
Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of a Official Receipt/Certificate of Registration for Motor Vehicle issued by LTO
with registered owner Gina H.Daymiel/William S. Daymiel, with the following details:

MV File No. 1001-00000120232 Make/Type: Mitsubishi Engine No.3A92UCS7536

Chassis Series: MIRAGE G4 GLS Plate No. KCU4161

No.:MMBSTA13AFH017417

That last week of February 28, 2020, I tried to locate the OR/certificate of registration from the folder
where I kept all of my important documents and other claims but it was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said OR/CR.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2020, at
Dipolog City.
 GINA H. DAYMIEL
(Affiant)
TIN#272-853-310

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2020, at Dipolog City.

Doc No. _____ IVO M. MANDANTES,CPA

Page No. _____ NOTARY PUBLIC FOR ZAMBOANGA DELNORTE
Book No. ____ VALID UNTIL 12-31-2021
Series of 2020 COMMISSION NO.SN:ZDN-DPL-013-2020
PTR NO.1945342,1/02/2020
IBP NO.095495,11/22/2019 for 2020
ATTORNEY’S ROLL NO. 65014
LAPU-LAPU ST. DIPOLOG CITY

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS
I, EARLKIRK LIM ADRIATICO, of legal age, Filipino, a resident of 507 Lapu-lapu St., Estaka, DIpolog City,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of Social Security System(SSS) Identification Card(ID).

That on February 28, 2020 while I was trying to locate my SSS ID from my file I found out that my SSS
ID was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said SSS ID.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2020, at
Dipolog City.

EARLKIRK LIM ADRIATICO

(Affiant)
SSS#1006954188

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2020, at Dipolog City.

Doc No. _____ IVO M. MANDANTES,CPA

Page No. _____ NOTARY PUBLIC FOR ZAMBOANGA DELNORTE
Book No. ____ VALID UNTIL 12-31-2021
Series of 2020 COMMISSION NO.SN:ZDN-DPL-013-2020
PTR NO.1945342,1/02/2020
IBP NO.095495,11/22/2019 for 2020
ATTORNEY’S ROLL NO. 65014
LAPU-LAPU ST. DIPOLOG CITY

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS
I, LURIEL BARAQUIA-CHUA, of legal age, Filipino, married, a resident of Poblacion Alto, Sergio
Osmena, Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose
and state:

That I am a holder and possessor of Social Security System(SSS) Identification Card(ID).

That on February 23, 2020 while I was trying to locate my SSS ID from my file I found out that my SSS
ID was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said SSS ID.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2020, at
Dipolog City.

LURIEL BARAQUIA-CHUA
(Affiant)
Driver’s License#J01-98-025611

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2020, at Dipolog City.

Doc No. _____ IVO M. MANDANTES,CPA

Page No. _____ NOTARY PUBLIC FOR ZAMBOANGA DELNORTE
Book No. ____ VALID UNTIL 12-31-2021
Series of 2020 COMMISSION NO.SN:ZDN-DPL-013-2020
PTR NO.1945342,1/02/2020
IBP NO.095495,11/22/2019 for 2020
ATTORNEY’S ROLL NO. 65014
LAPU-LAPU ST. DIPOLOG CITY

Doc. No.__
Page No.__
Book No.__
Series of 2020
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, BERNARDITA C. DINOPOL of legal age, Filipino, widow, and resident of

Pob. South, Polanco, Zamboanga del Norte, after having been duly sworn in
accordance with law, hereby depose and state:

That I am the spouse of late Anecito T. Dinopol, Sr. who was holder and
possessor of a Passbook with SA # 10A003581 issued by Rural Bank of
Rizal-Polanco ZN Branch. That upon his death, I became the possessor of
the said passbook.

That on January 29, 2020, while I was trying to look for the said passbook
from the file folder where I kept it, I found out that the passbook was lost,
and could not be found;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost;

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

foregoing statements and for the purpose of attesting to the loss of the said
Passbook issued by Rural Bank of Rizal.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2020, at Dipolog City.

BERNARDITA C. DINOPOL
(Affiant)
OSCA ID#18-00947-Polanco,ZN
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2020, at

Dipolog City.
Doc No. _____ IVO M. MANDANTES,CPA
Page No. _____ NOTARY PUBLIC FOR ZAMBOANGA DELNORTE
Book No. ____ VALID UNTIL 12-31-2021
Series of 2020 COMMISSION NO.SN:ZDN-DPL-013-2020
PTR NO.1945342,1/02/2020
IBP NO.095495,11/22/2019 for 2020
ATTORNEY’S ROLL NO. 65014
LAPU-LAPU ST. DIPOLOG CITY

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF NON-LOSS

I, GEMMA ELUMBA MONTEZA, of legal age, Filipino, married, a resident of Purok 4, Betlehem,
Polanco, Zamboanga del Norte after having been duly sworn in accordance with law, hereby
depose and state:

That I was a holder of a Philippine Passport which was issued to me and to my name by
Department of Foreign Affairs. I used my passport for my work as Overseas Filipino
Worker(OFW) in Iraq. Sometime, February 5, 2020 I was one of the OFWs repatriated by the
Philippine government due to security concerns in Iraq. That on that day as I was getting out
of my employer in Iraq I asked my passport but my employer refused to give my passport
back. So I asked the personnel from Department of Foreign Affairs what should I do and they
advised me that they will issue me travel document despite the absence of my passport;

That, thereafter, I insisted on getting out and went to the embassy of the Philippines in Iraq
without my passport and then I was issued a travel document and went home;
That, I honestly and in good faith state that my passport is now beyond recovery and
considered lost;

As such, I am executing this Affidavit of Non-recovery to attest to the truth of the foregoing
statements and for the purpose of re-issuance/reclaiming my passport by DFA.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2020,
at Dipolog City.

GEMMA ELUMBA MONTEZA

(Affiant)
VIN#72100021BB2376GEM20002-0

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2020, at Dipolog City.

Doc No. _____ IVO M. MANDANTES,CPA

Page No. _____ NOTARY PUBLIC FOR ZN,CITIES OF DIPOLOG/DAPITAN
Book No. ____ VALID UNTIL 12-31-2021
Series of 2020 COMMISSION NO.SN:ZDN-DPL-013-2020
PTR NO.1945342,1/02/2020-Dipolog City
IBP NO.095495,11/22/2019 for CY2020
ATTORNEY’S ROLL NO. 65014
LAPU-LAPU ST. ESTAKA,DIPOLOG CITY

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ELISA A. AGUILOR- CAJOCON, of legal age, Filipino, married, a resident of Letapan, Polanco,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:
That I am a holder and possessor of a Philippine Passport issued by the Department of Foreign Affairs.

That sometime year 2018, when I arrived at our house I checked my said passport from my bag . I
found out that my passport was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said passport.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2020, at
Dipolog City.

ELISA A. AGUILOR-CAJOCON
(Affiant)
Pag-ibig MID#1760-0034-7306

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2020, at Dipolog City.

Doc No. _____ IVO M. MANDANTES,CPA

Page No. _____ NOTARY PUBLIC FOR ZN,CITIES OF DIPOLOG/DAPITAN
Book No. ____ VALID UNTIL 12-31-2021
Series of 2020 COMMISSION NO.SN:ZDN-DPL-013-2020
PTR NO.1945342,1/02/2020-Dipolog City
IBP NO.095495,11/22/2019 for CY2020
ATTORNEY’S ROLL NO. 65014
LAPU-LAPU ST. ESTAKA,DIPOLOG CITY
Doc No. _____ IVO M. MANDANTES,CPA
Page No. _____ NOTARY PUBLIC FOR ZAMBOANGA DELNORTE
Book No. ____ VALID UNTIL 12-31-2021
Series of 2020 COMMISSION NO.SN:ZDN-DPL-013-2020
PTR NO.1945342,1/02/2020
IBP NO.095495,11/22/2019 for 2020
ATTORNEY’S ROLL NO. 65014
LAPU-LAPU ST. DIPOLOG CITY

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF EXPLANATION

I, ARCELITA O. ENGUITO, of legal age, Filipino, single, a resident of Olingan, Dipolog City,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose
and state:

That I was an applicant of a Philippine Passport which was issued to me and to my name by
Department of Foreign Affair. That I have claimed and received my passport through
assistance of agent; That, I lost my passport thereafter;

That, I re-applied for a passport and I mistakenly failed to declare and disclose that I had a
passport issued to me by DFA since upon application of passport I mistakenly checked portion
of “new” passport since I am getting a new passport;

That, I honestly and in good faith applied for passport so that I could a new passport and could
travel abroad;

As such, I am executing this Affidavit of Explanation to attest to the truth of the foregoing
statements and for the purpose of re-issuance/claiming my passport from DFA.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2020,
at Dipolog City.

ARCELITA O. ENGUITO
(Affiant)
ID#___________

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2020, at Dipolog City.

Doc No. _____ IVO M. MANDANTES,CPA

Page No. _____ NOTARY PUBLIC FOR ZAMBOANGA DELNORTE
Book No. ____ VALID UNTIL 12-31-2021
Series of 2020 COMMISSION NO.SN:ZDN-DPL-013-2020
PTR NO.1945342,1/02/2020
IBP NO.095495,11/22/2019 for 2020
ATTORNEY’S ROLL NO. 65014
LAPU-LAPU ST. DIPOLOG CITY

Doc. No.__
Page No.__
Book No.__
Series of 2019
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, MARICRIS R. BUHI AN, of legal age, Filipino, single, a resident of Igot, Estaka, Dipolog City after
having been duly sworn in accordance with law, hereby depose and state:

That I am the daughter of Jovita Buhian, holder and possessor of a Certificate of Registration BIR Form
No 2303 with OCN 2RC000033841 issued by Bureau of Internal Revenue.

That after the death of my mother Jovita Buhian, I searched all the documents she owned and
possessed. When I tried to locate the said Certificate of Registration(CR), I found out that said CR was
lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said Certificate of Registration.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2020, at
Dipolog City.

MARICRIS BUHI AN
(Affiant)
Driver’s License#J01-05-002968
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2020, at Dipolog City.

Doc No. _____ IVO M. MANDANTES,CPA

Page No. _____ NOTARY PUBLIC FOR ZAMBOANGA DELNORTE
Book No. ____ VALID UNTIL 12-31-2021
Series of 2020 COMMISSION NO.SN:ZDN-DPL-013-2020
PTR NO.1945342,1/02/2020
IBP NO.095495,11/22/2019 for 2020
ATTORNEY’S ROLL NO. 65014
LAPU-LAPU ST. DIPOLOG CITY
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, GEORGE F, of legal age, Filipino, married, a resident of Coliseum Area Taclobo, Dumaguete City
after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of a receipt with RL,EPEB No.2020000289 issued by Register of
Deeds for Zamboanga del Norte.

That on the same date, while I was trying to look for my said receipt from my file folder, then I found
out that my receipt was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said receipt and reissuance of the same and claiming the
documents particularly the Certificate of title for Lot No.16, Block 11, at the Register of Deeds for
Zamboanga del Norte anent to the receipt.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2020, at
Dipolog City.

GEORGE F. BENLOT
(Affiant)
Driver’s License#G02-03-000199

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2020, at Dipolog City.

Doc No. _____ IVO M. MANDANTES,CPA

Page No. _____ NOTARY PUBLIC FOR ZAMBOANGA DELNORTE
Book No. ____ VALID UNTIL 12-31-2021
Series of 2020 COMMISSION NO.SN:ZDN-DPL-013-2020
PTR NO.1945342,1/02/2020
IBP NO.095495,11/22/2019 for 2020
ATTORNEY’S ROLL NO. 65014
LAPU-LAPU ST. DIPOLOG CITY
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, PAMELA OCUPE TRIAMBULO, of legal age, Filipino, married, a resident of Pob. South, Polanco,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of a Philippine Passport issued by the Department of Foreign Affairs.

That on January 31, 2020, when I arrived at our house I checked my said passport from my bag . I
found out that my passport was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said passport.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2020, at
Dipolog City.

PAMELA OCUPE TRIAMBULO

(Affiant)
SSS ID#10-0722557-3

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2020, at Dipolog City.

Doc No. _____ IVO M. MANDANTES,CPA

Page No. _____ NOTARY PUBLIC FOR ZAMBOANGA DELNORTE
Book No. ____ VALID UNTIL 12-31-2021
Series of 2020 COMMISSION NO.SN:ZDN-DPL-013-2020
PTR NO.1945342,1/02/2020
IBP NO.095495,11/22/2019 for 2020
ATTORNEY’S ROLL NO. 65014
LAPU-LAPU ST. DIPOLOG CITY
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, EMMYLOU T. ALAWI, of legal age, Filipino, single, and resident of Look,

Estaka, Dipolog City, Zamboanga del Norte, after having been duly sworn in
accordance with law, hereby depose and state:

That I am the live-in partner of late Vergel Labuca Guillano who was holder
and possessor of a Passbook issued by Katipunan Bank.-Dipolog City. That
upon his death, I became the possessor of the said passbook.

That on January 29, 2020, while I was trying to look for the said passbook
from the file folder where I kept it, I found out that the passbook was lost,
and could not be found;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost;

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

foregoing statements and for the purpose of attesting to the loss of the said
Passbook issued by Katipunan Bank.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2020, at Dipolog City.

EMMYLOU T. ALAWI
(Affiant)
Philhealth ID#14-050213034-6
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2020, at

Dipolog City.

Doc No. _____ IVO M. MANDANTES,CPA

Page No. _____ NOTARY PUBLIC FOR ZAMBOANGA DELNORTE
Book No. ____ VALID UNTIL 12-31-2021
Series of 2020 COMMISSION NO.SN:ZDN-DPL-013-2020
PTR NO.1945342,1/02/2020
IBP NO.095495,11/22/2019 for 2020
ATTORNEY’S ROLL NO. 65014
LAPU-LAPU ST. DIPOLOG CITY

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, JOSELITO SALAC TIZON, of legal age, Filipino, married, a resident of

Punta, Dipolog City, Zamboanga del Norte, after having been duly sworn in
accordance with law, hereby depose and state:

That I am a holder and possessor of a Passbook with Savings Account No.

11555008699 issued by 1st Valley Bank, Inc.-Dipolog City

That on January 28, 2020, while I was trying to look for the said passbook
from the file folder I kept it, I found out that the passbook was lost, and
could not be found;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost;

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

foregoing statements and for the purpose of attesting to the loss of the said
Passbook issued by 1st Valley Bank.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2020, at Dipolog City.

JOSELITO S. TIZON
(Affiant)
PRC ID#0223233-Professional Teacher
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2020, at

Dipolog City.

Doc No. _____ IVO M. MANDANTES,CPA

Page No. _____ NOTARY PUBLIC FOR ZAMBOANGA DELNORTE
Book No. ____ VALID UNTIL 12-31-2021
Series of 2020 COMMISSION NO.SN:ZDN-DPL-013-2020
PTR NO.1945342,1/02/2020
IBP NO.095495,11/22/2019 for 2020
ATTORNEY’S ROLL NO. 65014
LAPU-LAPU ST. DIPOLOG CITY

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, RINALYN SABANAL GALLEPOSO, of legal age, Filipino, married, a resident of Brgy. East Poblacion,
Manukan, Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose
and state:

That I am a holder and possessor of a Philippine Passport issued by the Department of Foreign Affairs.

That on January 14, 2020, when I arrived at our house I checked my said passport from my bag which
was opened while I was traveling from Dipolog City going to Manukan. I found out that my passport
was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said passport.
IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019, at
Dipolog City.

RINALYN SABANAL GALLEPOSO

(Affiant)
POSTAL ID#PRN M83170592983P

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.

Doc No. _____ IVO M. MANDANTES,CPA

Page No. _____ NOTARY PUBLIC FOR ZAMBOANGA DELNORTE
Book No. ____ VALID UNTIL 12-31-2021
Series of 2020 COMMISSION NO.SN:ZDN-DPL-013-2020
PTR NO.1945342,1/02/2020
IBP NO.095495,11/22/2019 for 2020
ATTORNEY’S ROLL NO. 65014
LAPU-LAPU ST. DIPOLOG CITY

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS
I, ELMA S. LOYLOY, of legal age, Filipino, married to Francisco T. Loyloy, a
resident of Estaka, Dipolog City, Zamboanga del Norte, after having been
duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of a Passbook with Savings Account No.

33801000171-5 issued by Philippine Business Bank-Dipolog City

That on January 23 2020, while I was trying to look for the said passbook
from the place I kept it, I found out that the passbook was lost, and could
not be found;

That despite effort to recover the same but it was naught. Hence, I
considered it as totally lost;

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

foregoing statements and for the purpose of attesting to the loss of the said
Passbook issued by Philippine Business Bank.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________ 2020, at Dipolog City.

ELMA S. LOYLOY
(Affiant)
PRC ID#0058915
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2020, at

Dipolog City.

Doc No. _____ IVO M. MANDANTES,CPA

Page No. _____ NOTARY PUBLIC FOR ZAMBOANGA DELNORTE
Book No. ____ VALID UNTIL 12-31-2021
Series of 2020 COMMISSION NO.SN:ZDN-DPL-013-2020
PTR NO.1945342,1/02/2020
IBP NO.095495,11/22/2019 for 2020
ATTORNEY’S ROLL NO. 65014
LAPU-LAPU ST. DIPOLOG CITY
Doc No.
Page No.
Book No.
Series of 2020

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, LEILA D. CARREON-LAGUTAN, of legal age, Filipino, married, a resident of Lawaan, Banonong,

Dapitan City, Zamboanga del Norte after having been duly sworn in accordance with law, hereby
depose and state:

That I am a graduate of Bachelor of Science in Commerce, Major in Economics at Saint Vincent’s

College, Dipolog City in year 1979. I was a holder and possessor of a Diploma issued by Saint Vincent’s
College.

That in the first week of December, 2019, while I was trying to locate the said diploma, but it was lost
and could not be found;
That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said Diploma.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2020, at
Dipolog City.

LEILA D. CARREON-LAGUTAN
(Affiant)
DPWH ID#87L0024, 3rd DEO, Segabe Pinan,ZN

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2020, at Dipolog City.

Doc No. _____ IVO M. MANDANTES,CPA

Page No. _____ NOTARY PUBLIC FOR ZAMBOANGA DELNORTE
Book No. ____ VALID UNTIL 12-31-2021
Series of 2020 COMMISSION NO.SN:ZDN-DPL-013-2020
PTR NO.1945342,1/02/2020
IBP NO.095495,11/22/2019 for 2020
ATTORNEY’S ROLL NO. 65014
LAPU-LAPU ST. DIPOLOG CITY
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, FRANCISCO CRISPO C. CAMBARE, of legal age, Filipino, a resident of Dipolog City, Zamboanga
del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am an owner of a motorcycle Honda XRM with Plate No. 6099 JI. That the said
motorcycle was purchased the previous owner told me that the original Plate Number was lost

That I was trying to locate the said plate number, but it was lost and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements
and for the purpose of attesting to the loss of the said receipt.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2020,
at Dipolog City.

FRANCISCO CRISPO C. CAMBARE

(Affiant)
Driver’s License#K04-05-001601

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2020, at Dipolog City.

Doc No. _____ IVO M. MANDANTES,CPA

Page No. _____ NOTARY PUBLIC FOR ZAMBOANGA DELNORTE
Book No. ____ VALID UNTIL 12-31-2021
Series of 2020 COMMISSION NO.SN:ZDN-DPL-013-2020
PTR NO.1945342,1/02/2020
IBP NO.095495,11/22/2019 for 2020
ATTORNEY’S ROLL NO. 65014
LAPU-LAPU ST. DIPOLOG CITY
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, LHYNETTE ADANTE CALLAO, of legal age, Filipino, a resident of Olingan, Dipolog City,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose
and state:

That I am a holder of Receipt No. 0445-2019-02534 issued by ML Lhuillier re: Pawned

Jewelries.

That in the first week of December, 2019, while I was trying to locate the said receipt, but it
was lost and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements
and for the purpose of attesting to the loss of the said receipt.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2020,
at Dipolog City.

LHYNETTE ADANTE CALLAO

(Affiant)
ID#_________________________

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2020, at Dipolog City.

Doc No. _____ IVO M. MANDANTES,CPA

Page No. _____ NOTARY PUBLIC FOR ZAMBOANGA DELNORTE
Book No. ____ VALID UNTIL 12-31-2021
Series of 2020 COMMISSION NO.SN:ZDN-DPL-013-2020
PTR NO.1945342,1/02/2020
IBP NO.095495,11/22/2019 for 2020
ATTORNEY’S ROLL NO. 65014
LAPU-LAPU ST. DIPOLOG CITY
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, CECILIA BALUNTANG EBA, of legal age, Filipino, married, a resident of Guinles, Polanco,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose
and state:
That I am a graduate of Bachelor of Community Health Service at Pamantasan ng Lungsod ng
Maynila(PLM) on March 4, 2001. I was issued a Diploma issued by PLM.

That in the first week of December, 2019, while I was trying to locate the said diploma, but it
was lost and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements
and for the purpose of attesting to the loss of the said Diploma and request for issuance of
another.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2020,
at Dipolog City.

CECILIA B. EBA
(Affiant)
PRC ID#0042180-Midwife
Valid until 11/21/2020

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2020, at Dipolog City.

Doc No. _____ IVO M. MANDANTES,CPA

Page No. _____ NOTARY PUBLIC FOR ZAMBOANGA DELNORTE
Book No. ____ VALID UNTIL 12-31-2021
Series of 2020 COMMISSION NO.SN:ZDN-DPL-013-2020
PTR NO.1945342,1/02/2020
IBP NO.095495,11/22/2019 for 2020
ATTORNEY’S ROLL NO. 65014
LAPU-LAPU ST. DIPOLOG CITY
Doc. No.__
Page No.__
Book No.__
Series of 2019

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ESTEBAN P. GUMELA, of legal age, Filipino, widower, a resident of Turno, Dipolog City, Zamboanga
del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of a Simcard issued by the TNT with No.09380271575
That sometime first week of January, 2020, while I was about to check my cellular phone containing
the abovementioned simcard number I found out that the phone was lost. I tried to locate the cellular
phone with the said sim;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said simcard number and for purpose of replacing the
same.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2020, at
Dipolog City.

ESTEBAN P. GUMELA
(Affiant)
TIN#271925959
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2020, at Dipolog City.

Doc No.
Page No.
Book No.
Series of 2020

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS
I, ESTEBAN P. GUMELA, of legal age, Filipino, widower, a resident of Turno, Dipolog City, Zamboanga
del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of a Passbook with Savings Account No. 10A002515 issued by Rural
Bank of Rizal(ZN), Inc.

That on December 9, 2019, while I was trying to look for the said passbook from the place I kept it, I
found out that the passbook was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said Passbook issued by Rural Bank of Rizal, Inc.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2020, at
Dipolog City.

ESTEBAN P. GUMELA
(Affiant)
TIN#271925959
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2020, at Dipolog City.

Doc No.
Page No.
Book No.
Series of 2020
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, CARLO VIC MACASARTE PUYOS, of legal age, Filipino, single, a resident of Busco, Quezon,
Bukidnon after having been duly sworn in accordance with law, hereby depose and state:

That I am an employee of UNAHCO, INC. with office address of Mandaluyong City.

That I was issued by the company of a Cellular Phone described as SAMSUNG GALAXY J6, Year
2016 Model. That the phone was eventually awarded to the undersigned, however, the Sim
Card was owned by the company.

That on January 9, 2020 at around 6 in the evening, I discovered that the said Cellular Phone
with Sim Card was not in my possession. I tried to locate the same and tried to contact the said
cellular phone number but my attempt failed because it just rang and nobody answered

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements
and for the purpose of attesting to the loss of the said company issued cellular phone with sim
card.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2020,
at Dipolog City.

CARLO VIC MACASARTE PUYOS

(Affiant)
Driver’s License No. K03-13-000396
Valid until 11/11/2023

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2020, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2020
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, PAULO C. ARGUILLA, of legal age, Filipino, married, a resident of Galas, Dipolog City,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose
and state:

That I am the buyer of a parcel of land with Lot 302-A, covered by Original Certificate of Title
No.P-26009 located at Dansullan, Polanco, Zamboanga del Norte.

That on December 30, 2019, I purchased the said parcel of land and executed the Deed of Sale.
That however, I later learned from the vendors that the owner’s duplicate copy of the said
certificate of title was lost.

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements
and for the purpose of attesting to the loss of the said owner’s duplicate copy of the certificate
of title.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2020,
at Dipolog City.

PAULO C. ARGUILLA
(Affiant)
SSS ID#10-0696334-4

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2020, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2020
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, CARLA G. JAMAROLIN, of legal age, Filipino, married, a resident of Dawo, Dapitan City after having
been duly sworn in accordance with law, hereby depose and state:

That I held the raffle draw ticket of Ma. Teresa G. Caballero with No. 0190 for Pa-Raffle Sa Pasko 2019
issued by Samahan ng mga Kawani ng Dr. Jose Rizal Memorial Hospital(SKDJRMH) because I was the
one who purchased the said ticket.

That on December 30, 2019, I found out that the raffle ticket with said number of 0190 won Second
Prize worth of P10,000.00. I was overjoyed and felt the euphoria that I jumped and bellowed with so
much conviction that I could immediately claim the coveted prize. I told my family and friends that
the ticket I purchased won. Then I immediately went to the claiming place of the prize with
confidence that the winning ticket was in my pricy bag. When I was there, I checked my bag but it was
not there, thus I found out that ticket was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said ticket with no.0190 and claiming the coveted prize of
P10,000.00.

IN WITNESS WHEREOF, I have hereunto affixed my signature this 31st day of December 2019, at
Dipolog City.

CARLA G. JAMAROLIN
(Affiant)
PRC ID#0026871-Pharmacist
With Photo

SUBSCRIBED AND SWORN to before me this 31st day of December 2019, at Dipolog City.

Doc No. _____ IVO M. MANDANTES, CPA

Page No. _____ NOTARY PUBLIC FOR ZAMBOANGA DEL
NORTE
Book No. ____ UNTIL 12-31-2021
Series of 2019 COMMISSION NO.ZDN-DPL-013-2021
ATTORNEY’S ROLL NO. 65014
PTR NO. 1945342-1/2/2020-Dipolog City
IBP NO.095495-11/22/2019 for 2020
LAPU-LAPU ST. DIPOLOG CITY

Doc. No
Page No
Book No.
Series of 2019
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT

I, JEGGER BUSCA PADELA, of legal age, Filipino, married, a resident of Lower Gumay, Pi ñan,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose
and state:

That I am the owner and possessor of licensed firearms, described as follows:

MAKE KIND FA LIC. NO. SERIAL NO.

PISTL GLCK 545835I2289354 AACF791

PISTL ARMSCOR 0545835I01158469 959847

That on December 31, 2019 at about 4 in the afternoon, I checked my expendable bag at my
room where I placed the abovesaid firearms I found out that the said firearms were nowhere
to be found;

That I immediately reported to the police station regarding the loss of my firearms;

That despite effort to recover the same but it was naught.

Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements
and for the purpose of attesting to the loss of the said firearms.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2020,
at Dipolog City.

JEGGER BUSCA PADELA

(Affiant)
 AFP ID# A19-E-199331

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2020, at Dipolog City.

Doc. No.__
Page No.__
Book No.__
Series of 2019

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, KAREN HAZEL R. BAROY, of legal age, Filipino, married, a resident of Conacon, Pob. North, Polanco,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of Honorable Dismissal and Good Moral Character documents issued
by the school.

That sometime December, 2019, while I was checking my bag, I found out that said document was
lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said documents.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019, at
Dipolog City.

KAREN HAZEL R. BAROY

(Affiant)
ID#_______________________

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.

Doc No. _____ IVO M. MANDANTES, CPA

Page No. _____ NOTARY PUBLIC FOR ZN
Book No. ____ UNTIL 12-31-2019
Series of 2019 COMMISSION NO.ZDN-DPL-022-2018
ROLL NO. 65014
LAPU-LAPU ST. DIPOLOG CITY
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ELIZABETH O. CUDAL, of legal age, Filipino, married, a resident of Estaka, Dipolog City, Zamboanga
del Norte after having been duly sworn in accordance with law, hereby depose and state:

That being one of the heirs of Fulgencio Ortega and Dominga Ortega, I became a holder and possessor
of a BIR issued copy of Certificates Authorizing Registration(CARs) with its duplicate, official receipts
and Tax returns for the Deed of Extrajudicial Settlement of the Estate of Fulgencio R. Ortega and
Dominga P. Ortega notarized by Michael Alan Ranillo per Doc. No. 7932, Page No.42, Book No.179,
Series of 2016 and its Addendum with the same notary public per Doc. No. 12913, Page No.37, Book
No.208, Series of 2018.

That in December 2019, while I was checking my file folder containing the said documents. Then, I
found out that CAR for the shares of stocks of the decedents was lost, and could not be found; That
the only CARs that could be found are the CAR for estate tax of the real property and capital gains
tax/documentary stamp tax of the real property of the decedents.
That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said documents and requesting for the issuance of the
same.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019, at
Dipolog City.

ELIZABETH O. CUDAL
(Affiant)
OSCA iD#14323-Dipolog City

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.

Doc No. _____ IVO M. MANDANTES,CPA

Page No. _____ NOTARY PUBLIC FOR ZN
Book No. ____ UNTIL 12-31-2019
Series of 2019 COMMISSION NO.ZDN-DPL-022-2018
ROLL NO. 65014
LAPU-LAPU ST. DIPOLOG CITY

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, LETICIA MORGIA, of legal age, Filipino, married, a resident of Sta. Filomena, Dipolog City,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of a sepia copy and corresponding Technical Descriptions of
Approved Subdivision Plan Lot 1,PCS-097202-001398 for parcel of land situated at Sta. Filomena,
Dipolog City.

That sometime third week of October 2019, while I was checking my file folder containing the said
document so that I could process the land and its revision, I found out that the technical description
documents were lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.
As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said technical descriptions document.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019, at
Dipolog City.

LETICIA MORGIA
(Affiant)
OSCA ID#8617-Dipolog City

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.

Doc No. _____ IVO M. MANDANTES,CPA

Page No. _____ NOTARY PUBLIC FOR ZN
Book No. ____ UNTIL 12-31-2019
Series of 2019 COMMISSION NO.ZDN-DPL-022-2018
ROLL NO. 65014
LAPU-LAPU ST. DIPOLOG CITY

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, RAMIL V. MAPULA, of legal age, Filipino, single, a resident of Lopez Subd.,Tugbungan, Zamboanga
City after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of a slip of BIR Claim Slip#0911019-0022mon October 3, 2019 issued
by Bureau of Internal Revenue.

That on the same date, while I was trying to look for my said claim stub from my file folder, then I
found out that my claim slip was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;
As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said claim slip and reissuance of the same and claiming the
documents at the Bureau of Internal Revenue anent to the slip.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019, at
Dipolog City.

RAMIL V. MAPULA
(Affiant)
Driver’s License#J13-18-006018 valid until 7/23/2022
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.

Doc No. _____ IVO M. MANDANTES, CPA

Page No. _____ NOTARY PUBLIC FOR ZAMBOANGA DEL NORTE
Book No. ____ UNTIL 12- DIPOLOG 31-2019
Series of 2019 COMMISSION NO.ZDN-DPL-022-2018
ATTORNEY’S ROLL NO. 65014
LAPU-LAPU ST. ESTAKA, DIPOLOG CITY

Doc. No.__
Page No.__
Book No.__
Series of 2019
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS
I, MARY ANGELI P. NECESARIO, of legal age, Filipino, single, a resident of Opao, Dapitan City,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am the buyer of a parcel of land located at Barangay Galas, Dipolog City, more particularly
described as follows:

Transfer Certificate of Title No. P-1022

Beginning at point marked “1” of Lot 1, SGS-09-000091, Being S.18-52 W.,1,466.27 M.from
BLLLM No.2 Cad 85, Dipolog Cadastral Subdivision, Thence S.53.37 E.,E.,16.13M to point 2;S.39-37
W.,3500 m. to point 3;N.14-24 E.,31.83 m.to point 4; N.13-54E.,5.87 m. to point 1, point of beninning;
Containing an area of TWO HUNDRED EIGHTY_ONE(281) Square meter. Corner 11.2 are marked PS
and the rest are old BL Cyl. Conc.Mons.15X60 cms. Bounded on the NE along line 1-2 by lots 2,SGS-09-
000091 on the SE, along lone 2-3 by National Highway(20.00 m.wide); on the West along line 3-4-1 by
National Highway(20.00 m.wide).

Containing an area of TWO HUNDRED EIGHTY ONE(281) square meters, more or less.

That I bought the above-described property from Claudio Ortega last June 10, 2015;

That Claudio Ortega and his wife, the registered owners, are already dead so they could no longer
execute the affidavit. That when Claudio Ortega was still alive, he told the affiant that he kept the title
and discovered that it was lost. His family looked everywhere for the lost title which was in their
possession but to no avail;

That after the death of Claudio Ortega, the affiant also searched for the whereabouts of the title and
talked to all persons, including his heirs who could have possibly possessed the title. That the heirs of
Claudio Ortega are no longer interested in the property as it was already sold to the affiant;

That despite earnest efforts to locate the said title, all was to no avail and may validly be considered
as lost and/or misplaced for all intents and purpose of the law;

That the said title was never surrendered nor foreclosed or otherwise sold to any person;

As such, I am executing this affidavit of Loss of Transfer Certificate of title to attest the truth if the
foregoing and to support my application for issuance of new owner’s duplicate copy in lieu of lost
one.

IN WITNESS WHEREOF, I have hereunto affixed my signature this 18th day of December 2019, at
Dipolog City.

MARY ANGELI P. NECESSARIO

(Affiant)
Driver’s License#J01-03-040796
With Photo

SUBSCRIBED AND SWORN to before me this 18th day of December 2019, at Dipolog City.

Doc No. 2397 IVO M. MANDANTES, CPA

Page No. 70 NOTARY PUBLIC FOR ZAMBOANGA DEL
NORTE
Book No. V UNTIL 12- DIPOLOG 31-2019
Series of 2019 COMMISSION NO.ZDN-DPL-022-2018
ATTORNEY’S ROLL NO. 65014
LAPU-LAPU ST. ESTAKA, DIPOLOG CITY
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, CHARES R. CORDOVA, of legal age, Filipino, a resident of Pian, Polanco, Zamboanga del Norte after
having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of a Passbook with Account No. 276-0846010 issued by ChinaBank,
Dipolog City Branch in the name of PEPSI COLA PRODUCTS PHILS.,INC., as its Sales Office Teller.

That on December 9, 2019, while I was trying to look for the said passbook from the place I kept it, I
found out that the passbook was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said Passbook issued by Chinabank.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019, at
Dipolog City.

CHARES R. CORDOVA
(Affiant)
ID#_________________________
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.

Doc No. _____ IVO M. MANDANTES, CPA

Page No. _____ NOTARY PUBLIC FOR ZAMBOANGA DEL NORTE
Book No. ____ UNTIL 12- DIPOLOG 31-2019
Series of 2019 COMMISSION NO.ZDN-DPL-022-2018
ATTORNEY’S ROLL NO. 65014
LAPU-LAPU ST. ESTAKA, DIPOLOG CITY
Doc. No.__
Page No.__
Book No.__
Series of 2019

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x
 AFFIDAVIT OF LOSS

I, ROLAND BALABA PIQUERO, of legal age, Filipino, married, a resident of Biayon, Sergio Osmena,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of a passbook issued by Katipunan Bank- Katipunan, ZN Branch.

That on December 10, 2019, while I was at Dipolog Integrated Bus Terminal and I was trying to look
for my said passbook from my bag, I found out that my passbook was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said Katipunan Bank Passbook.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019, at
Dipolog City.

ROLAND B. PIQUERO
(Affiant)
UMID ID#CRN-0111-8082354-6
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2019
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, JOHN PAUL B. HAYO, of legal age, Filipino, a resident of resident of Manukan, Zamboanga del Norte
after having been duly sworn in accordance with law, hereby depose and state:

That I am Branch Manager of 1st Valley Bank, Inc.-Manukan, Zamboanga del Norte Branch. That as a
manager, I am responsible of bank document like bank stub;

That on November 30, 2019, I was checking the stubs, I found out that the Stub with No. 500, Series
No.24951-25000 was lost, and could not be found. I believe that the stub was lost already;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said stub.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019, at
Dipolog City.

JOHN PAUL B. HAYO

(Affiant)
ID#___________________

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.

Doc No. _____ IVO M. MANDANTES, CPA

Page No. _____ NOTARY PUBLIC FOR ZAMBOANGA DEL NORTE
Book No. ____ UNTIL 12- DIPOLOG 31-2019
Series of 2019 COMMISSION NO.ZDN-DPL-022-2018
ATTORNEY’S ROLL NO. 65014
LAPU-LAPU ST. ESTAKA, DIPOLOG CITY
Doc. No.__
Page No.__
Book No.__
Series of 2019

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, RENZJAY G. CURADO, of legal age, Filipino, single, a resident of Letapan, Polanco, Zamboanga del
Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of a Non-Professional Driver’s License with official receipt issued by
Land Transportation Office, Dipolog City.

That on December 8, 2019, at around 11pm while I was walking at Polanco Plaza in Polanco,ZN and
checking my license from my pocket, then I found out that my driver’s license was lost, and then it
could not be found;
That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said driver’s license and the official receipt.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019, at
Dipolog City.

RENZJAY G. CURADO
(Affiant)
JRMSU School IDoff#15DF200702

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.

Doc No. _____ IVO M. MANDANTES, CPA

Page No. _____ NOTARY PUBLIC FOR ZAMBOANGA DEL NORTE
Book No. ____ UNTIL 12- DIPOLOG 31-2019
Series of 2019 COMMISSION NO.ZDN-DPL-022-2018
ATTORNEY’S ROLL NO. 65014
LAPU-LAPU ST. ESTAKA, DIPOLOG CITY

Doc. No.__
Page No.__
Book No.__
Series of 2019
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ELVIZA BETERAN DUARTE, of legal age, Filipino, single, a resident of Brgy. Dionum, Piñan,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of a Philippine Passport issued by the Department of Foreign Affairs.

That on November 16, 2018, when I arrived at our house I checked my said passport from my file
documents. I found out that my passport was lost, and could not be found; I checked my passport
because I intend to travel abroad;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said passport.
IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019, at
Dipolog City.

Driver’s
ELVIZA BETERAN DUARTE
(Affiant)
ID#__________________________

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.

Doc No. _____ IVO M. MANDANTES, CPA

Page No. _____ NOTARY PUBLIC FOR ZAMBOANGA DEL NORTE
Book No. ____ UNTIL 12- DIPOLOG 31-2019
Series of 2019 COMMISSION NO.ZDN-DPL-022-2018
ATTORNEY’S ROLL NO. 65014
LAPU-LAPU ST. ESTAKA, DIPOLOG CITY

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, EDGARDO P. MERTALLA, of legal age, Filipino, married, a resident of San Antonio, Manukan,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of a Official Receipt/Certificate of Registration for Motor Vehicle issued by LTO with
registered owner John Ronar H. Daguinotas, with the following details:

MV File(Temporary Make/Type: HONDA Engine No.JF78E7027090

Plate):090110/0901375729

Chassis CR NO.:324706093 Fuel:GAS

No.:MH1JF7876JK027894

That last week of November 2019, I tried to locate the OR/certificate of registration from the folder
where I kept all of my important documents and other claims but it was lost, and could not be found;
That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said OR/CR.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019, at
Dipolog City.

EDGARDO P. MERTALLA
(Affiant)
ID#_________________________

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2019

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, MARLON BALOALOA BRIONES, of legal age, Filipino, married, a resident of Del Pilar, Pinan,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of a AFPMBAI Basic Certificate issued by AFPMBAI being a member
of the Armed Forces of the Philippines.
That last week of November 2019, I tried to locate the certificate from the folder where I kept all of
my important documents so that I could claim my retirement benefits and other claims but it was lost,
and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said AFPMBAI Basic Certificate.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019, at
Dipolog City.

MARLON BALOALOA BRIONES

(Affiant)
AFP ID#A19-E-217652

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2019
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ROSELLER J. LIMBAGO, of legal age, Filipino, married, a resident of Turno, Dipolog City, Zamboanga
del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of a receipt issued by Register of Deeds for Zamboanga del Norte
with EPEB NO. 2018001461.

That on August 30, 2019, I tried to locate the receipt from the folder where I kept all of my important
documents so that I could claim the Certificate of title but it was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said receipt with EPEB NO. 2018001461.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019, at
Dipolog City.

ROSELLER J. LIMBAGO
(Affiant)
Non-Prof. Driver’s License#N26-01-055269

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2019
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, JOSEL MAY SALOMON, of legal age, Filipino, single, a resident of Isis, Polanco, Zamboanga del Norte
after having been duly sworn in accordance with law, hereby depose and state:

That I am a possessor of an official receipt issued by Cebuanna Lhuillier for a pawned jewelry with
Pawn Ticket No.50303SG052239.

That on August 30, 2019, I tried to locate the receipt but it was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said receipt of Cebuana Lhuillier.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019, at
Dipolog City.

JOSEL MAY SALOMON

(Affiant)
ID#_______________________

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2019
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, GUILLERMO T. LITERATUS, of legal age, Filipino, a resident of Poblacion East, Salug, Zamboanga del
Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of PRC Identification Card being a Doctor of Medicine.

That on November 25, 2019, while I was checking the folder of my bag containing all my documents
to search for my PRC ID because it is due for renewal this March 27, 2020, I found out that my PRC ID
was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said PRC ID.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019, at
Dipolog City.

GUILLERMO T. LITERATUS
(Affiant)
OSCA iD#203-Salug, Zamboanga del Norte

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2019
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, GIL D. RECAMARA, of legal age, Filipino, married, a resident of New Sicayab, Polanco, Zamboanga
del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of a Certificate of Registration with Official receipt(OR/CR) issued by
Land Transportation Office.

That details of the motor vehicle registered in my name is described as follows:

Make: HONDA Plate No. TEMP 090102

Engine No. KPY00E129360 Chassis No. KPY00129363

MV File:0901-00000116036 CR No.:237593042

That in the last week of September, 2019, while I was trying to locate the said OR/CR from my folder, I
found out that the said OR/CR were lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said OR/CR.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019, at
Dipolog City.

GIL D. RECAMARA
(Affiant)
TIN#419-926-052
SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.

Doc No. _____ IVO M. MANDANTES, CPA

Page No. _____ NOTARY PUBLIC FOR ZN
Book No. ____ UNTIL 12-31-2019
Series of 2019 COMMISSION NO.ZDN-DPL-022-2018
ROLL NO. 65014
LAPU-LAPU ST. DIPOLOG CITY

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, FELIX M. CELICIOUS,JR., of legal age, Filipino, married, a resident of Biasong, Dipolog City,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of a Philippine Passport issued by the Department of Foreign Affairs.

That on September 21, 2019, when I arrived at our house I checked with my wife the said passport
from her file documents. I found out that my passport was lost, and could not be found; I checked my
passport because I intend to travel abroad;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said passport.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019, at
Dipolog City.

FELIX M. CELICIOUS,JR.
(Affiant)
OSCA ID#7972-Dipolog City

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.

Doc No. _____ IVO M. MANDANTES, CPA

Page No. _____ NOTARY PUBLIC FOR ZAMBOANGA DEL NORTE
Book No. ____ UNTIL 12- DIPOLOG 31-2019
Series of 2019 COMMISSION NO.ZDN-DPL-022-2018
ATTORNEY’S ROLL NO. 65014
LAPU-LAPU ST. ESTAKA, DIPOLOG CITY
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, SOLEDAD M. CELICIOUS, of legal age, Filipino, married, a resident of Biasong, Dipolog City,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of a Philippine Passport issued by the Department of Foreign Affairs.

That on September 21, 2019, when I arrived at our house I checked the said passport from my bag. I
found out that my passport was lost, and could not be found; I checked my passport because I intend
to travel abroad;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said passport.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019, at
Dipolog City.

SOLEDAD M. CELICIOUS
(Affiant)
OSCA ID#13299-Dipolog City

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.

Doc No. _____ IVO M. MANDANTES, CPA

Page No. _____ NOTARY PUBLIC FOR ZAMBOANGA DEL NORTE
Book No. ____ UNTIL 12- DIPOLOG 31-2019
Series of 2019 COMMISSION NO.ZDN-DPL-022-2018
ATTORNEY’S ROLL NO. 65014
LAPU-LAPU ST. ESTAKA, DIPOLOG CITY
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, RANDY L. BULAGAO, of legal age, Filipino, single, a resident of Bandera, Polanco, Zamboanga del
Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of a Driver’s License with official receipt issued by Land
Transportation Office, Dipolog City.

That in the last week of September, 2019, while I was checking my license from my wallet, then I
found out that my driver’s license was lost because I usually used the said license as proof of
identification, and then it could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said driver’s license.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019, at
Dipolog City.

RANDY L. BULAGAO
(Affiant)
Philhealth ID#15-025339596-8

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2019
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, EMERALD MAE E. NICOR, of legal age, Filipino, a resident of Dansullan, Polanco, Zamboanga del
Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of a Certificate of Registration with Official receipt(OR/CR) issued by
Land Transportation Office.

That details of the motor vehicle registered in my name is described as follows:

Make: YAMAHA Plate No. 090101

Engine No. R2582926 Chassis No. PA040C000E022327

Type of Body: MC Color:Yellow

That in the last week of September, 2019, while I was trying to locate the said OR/CR from my folder, I
found out that the said OR/CR were lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said OR/CR.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019, at
Dipolog City.
 EMERALD MAE E. NICOR
(Affiant)
Non-Prof. License#J01-13-001340

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.

Doc No. _____ IVO M. MANDANTES, CPA

Page No. _____ NOTARY PUBLIC FOR ZN
Book No. ____ UNTIL 12-31-2019
Series of 2019 COMMISSION NO.ZDN-DPL-022-2018
ROLL NO. 65014
LAPU-LAPU ST. DIPOLOG CITY

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, FORTUNATO BUENO LADERA, of legal age, Filipino, a resident of Sicayab, Dipolog City, Zamboanga
del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of a sepia copy and corresponding Technical Descriptions of
Approved Subdivision Plan PSD-09-028556.

That sometime third week of October 2019, while I was checking my file folder containing the said
document so that I could pick up the said seedling, I found out that it was lost, and could not be
found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said document.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019, at
Dipolog City.

FORTUNATO B. LADERA
(Affiant)
Driver’s License#J01-89-010053 valid until 2/2/2023

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.
Doc No. _____ IVO M. MANDANTES,CPA
Page No. _____ NOTARY PUBLIC FOR ZN
Book No. ____ UNTIL 12-31-2019
Series of 2019 COMMISSION NO.ZDN-DPL-022-2018
ROLL NO. 65014
LAPU-LAPU ST. DIPOLOG CITY

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, NILO G. AGUHOB, of legal age, Filipino, married, a resident of Aseniero, Dapitan City, Zamboanga del
Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of an official receipt issued by the Province of Zamboanga del Norte
in the amount of P5,000.00 for the purchase of bamboo culms.

That sometime third week of October 2019, while I was checking my file folder containing the said
document so that I could pick up the said seedling, I found out that it was lost, and could not be
found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said document.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019, at
Dipolog City.

NILO G. AGUHOB
(Affiant)
ID#___________________
SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.

Doc No. _____ IVO M. MANDANTES

Page No. _____ NOTARY PUBLIC FOR ZN
Book No. ____ UNTIL 12-31-2019
Series of 2019 COMMISSION NO.ZDN-DPL-022-2018
ROLL NO. 65014
LAPU-LAPU ST. DIPOLOG CITY

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, JEM KRISTEL MANDANTES, of legal age, Filipino, single, a resident of Isis, Polanco, Zamboanga del
Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of a BIR issued copy of CAR with No.201000322085 with its
duplicate and its tax returns.

That in January 2019, while I was checking my file folder containing the said documents. Then, I
inspected my bag I found out that copy of said CAR and Tax returns were lost, and could not be
found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said documents.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019, at
Dipolog City.

JEM KRISTEL MANDANTES

(Affiant)
TIN#917376568

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.
Doc No. _____ IVO M. MANDANTES
Page No. _____ NOTARY PUBLIC FOR ZN
Book No. ____ UNTIL 12-31-2019
Series of 2019 COMMISSION NO.ZDN-DPL-022-2018
ROLL NO. 65014
LAPU-LAPU ST. DIPOLOG CITY

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ROWINA DEMANA EGUAL, of legal age, Filipino, single, a resident of Gulayon, Dipolog City,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of a Philippine Passport issued by the Department of Foreign Affairs.

That on January 5 2017, while I arrived at our house I checked the said passport from my bag. Then,
when I inspected my bag I found out that my passport was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said passport.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019, at
Dipolog City.

ROWINA DEMANA EGUAL

(Affiant)
Passport# E240GRMA39-DR154463

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.

Doc No. _____ IVO M. MANDANTES

Page No. _____ NOTARY PUBLIC FOR ZN
Book No. ____ UNTIL 12-31-2019
Series of 2019 COMMISSION NO.ZDN-DPL-022-2018
ROLL NO. 65014
LAPU-LAPU ST. DIPOLOG CITY

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, CHARLES A. DUKA, of legal age, Filipino, married, a resident of Dipolog City, Zamboanga del Norte
after having been duly sworn in accordance with law, hereby depose and state:

That I am the Area Manager of GUD MOTO TRADING, INC. with branch office address of Gen. Luna
Ave., Dipolog City. That the branch office is a holder and possessor of a Certificate of Registration No.
254989151 with Official receipt No. 1394540770 issued by Land Transportation Office.

That details of the motor vehicle registered in the name of GUD MOTO T RADING, INC. is described as
follows:

Make: Mazda Plate No. ADN8510

Engine No. R2582926 Chassis No. SE28T200551

Series:Bongo MV File:0701-00000412343

That in the last week of September, 2019, while the office clerk was trying to locate the said OR/CR
from the office folder, we found out that the said OR/CR were lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said OR/CR.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019, at
Dipolog City.
 CHARLES A. DUKA
(Affiant)
ID#________________________

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.

Doc No. _____ IVO M. MANDANTES, CPA

Page No. _____ NOTARY PUBLIC FOR ZN
Book No. ____ UNTIL 12-31-2019
Series of 2019 COMMISSION NO.ZDN-DPL-022-2018
ROLL NO. 65014
LAPU-LAPU ST. DIPOLOG CITY

Doc. No.__
Page No.__
Book No.__
Series of 2019

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS
I, AILEEN C. ARQUIZA, of legal age, Filipino, married, a resident of Del Pilar, Piñan, Zamboanga del
Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of Honorable Dismissal and Good Moral Character documents issued
by Saint Vincent’s College, Dipolog City.

That sometime May, 2019, while I was checking my bag, I found out that said document was lost, and
could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said documents.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019, at
Dipolog City.

AILEEN C. ARQUIZA
(Affiant)
UMID ID#CRN-0111-7889997-7

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.

Doc No. _____ IVO M. MANDANTES, CPA

Page No. _____ NOTARY PUBLIC FOR ZN
Book No. ____ UNTIL 12-31-2019
Series of 2019 COMMISSION NO.ZDN-DPL-022-2018
ROLL NO. 65014
LAPU-LAPU ST. DIPOLOG CITY
Doc. No.__
Page No.__
Book No.__
Series of 2019

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, LENLIE ATAD ACOSTA, of legal age, Filipino, married, a resident of Purok Bonifacio, Punta, DIpolog
City, Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and
state:

That I am a holder and possessor of a Philippine Passport issued by the Department of Foreign Affairs
which I renewed before the DFA. The DFA issued me an Official Receipt of my renewal of passport for
claiming;

That on October 10, 2019, while I was checking the folder where I kept the official receipt of my
passport, I found out that my passport’s official receipt was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.
As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said passport’s official receipt.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019, at
Dipolog City.

LENLIE ATAD ACOSTA

(Affiant)
Voter’s ID#72020287AE3176LAA20000

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.

Doc No. _____ IVO M. MANDANTES

Page No. _____ NOTARY PUBLIC FOR ZN
Book No. ____ UNTIL 12-31-2019
Series of 2019 COMMISSION NO.ZDN-DPL-022-2018
ROLL NO. 65014
LAPU-LAPU ST. DIPOLOG CITY

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, RITA LIMOSNERO REBUYON, of legal age, Filipino, married, a resident of Purok Bonifacio, Punta,
DIpolog City, Zamboanga del Norte after having been duly sworn in accordance with law, hereby
depose and state:

That I am a holder and possessor of a Philippine Passport issued by the Department of Foreign Affairs
which I renewed before the DFA. The DFA issued me an Official Receipt of my renewal of passport for
claiming;

That on October 10, 2019, while I was checking the folder where I kept the official receipt of my
passport, I found out that my passport’s official receipt was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.
As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said passport’s official receipt.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019, at
Dipolog City.

RITA LIMOSNERO REBUYON

(Affiant)
UMID ID#CRN-0033-9658770-0

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.

Doc No. _____ IVO M. MANDANTES

Page No. _____ NOTARY PUBLIC FOR ZN
Book No. ____ UNTIL 12-31-2019
Series of 2019 COMMISSION NO.ZDN-DPL-022-2018
ROLL NO. 65014
LAPU-LAPU ST. DIPOLOG CITY

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, LORENZO ICAO EDDAI, of legal age, Filipino, married, a resident of Turno, Dipolog City, Zamboanga
del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of a Driver’s License with No. J01-72-001401 issued by Land
Transportation Office,Dipolog City.

That in the last week of September, 2019, while I was checking my folder at home, then I found out
that my driver’s license was lost because I usually used the said license as proof of identification on
the processing of our lot titling, and then it could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;
As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said driver’s license.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019, at
Dipolog City.

LORENZO I. EDDAI
(Affiant)
Driver’s License#J01-72-001401

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2019

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, JOSEPHINE M. CAVAN, of legal age, Filipino, married, a resident of Barra, Dipolog City, Zamboanga
del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of Certificate of Membership issued by KAPA Community

International Ministry.

That sometime October 2019, while I was at home I was informed that the Certificate of Membership
is necessary for me to claim my blessing, upon checking my file of documents I found out it was lost. I
tried to scan and search the said document but I failed. Thus, I considered the said Certificate of
Membership as lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said KAPA Certificate of Membership.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019, at
Dipolog City.

JOSEPHINE M. CAVAN
(Affiant)
ID#________________________

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2019

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, MAGDALENA GEBONE OBORDO, of legal age, Filipino, a resident of Crisotomo Ibarra St., Dawo,
Dapitan City, Zamboanga del Norte after having been duly sworn in accordance with law, hereby
depose and state:
That I am a holder and possessor of a Unified Multi-purpose ID(UMID) card with No. CRN-006-0041-
7305-0.

That sometime February 2019, while I was at Chonghua Hospital in Cebu City and I frequenltly used
the said card for discounts when I unintentionally lost the card. I waited for someone who might find
it but nobody approached. Thus, I considered my said UMID card as lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said UMID ID card.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019, at
Dipolog City.

MAGDALENA GEBONE OBORDO

(Affiant)
UMID ID#CRN-006-0041-7305-0

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2019

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, FRENCITO G. PASIGNA, of legal age, Filipino, a resident of VCH, Obay, Polanco, Zamboanga del Norte
after having been duly sworn in accordance with law, hereby depose and state:
That I am a holder and possessor of a Certificate of Registration for motor vehicle with Plate No.
9J2180 issued by Land Transportation Office,Dipolog City registered in the name of Lorena
Cagbabanua.

That on August 19, 2019, while I was trying going home, then I found out that my wallet containing
the said Certificate of Registration was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said Certificate of Registration.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019, at
Dipolog City.

FRENCITO G. PASIGNA
(Affiant)
OSCA ID#18-03592, Polanco,ZN

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2019

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x
 AFFIDAVIT OF LOSS

I, MARK ANDREI J. ROCAMORA, of legal age, Filipino, a resident of Dipolog City, Zamboanga del Norte
after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of a Driver’s License with Official receipt issued by Land
Transportation Office,Dipolog City.

That in the last week of September, 2019, while I was trying going home, then I found out that my
wallet containing my driver’s license was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said driver’s license.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019, at
Dipolog City.

MARK ANDREI J. ROCAMORA

(Affiant)
ID#________________________

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2019
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, JOSE C. BACOLCOL,JR., of legal age, Filipino, married, a resident of Orchid Villas, DIpolog City,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of a BIR issued copy of eCAR with No.201300106885 with its
duplicate and Tax returns namely, Creditable Withholding Tax Returns with OR No. A00107 issued by
PNB in the amount of P26,990.28 and with OR No. A00161, issued by PNB in the amount of
P16,620.00.

That in September 2019, while I was checking my file folder containing the said documents. Then, I
inspected my bag I found out that duplicate copy of eCAR with No.201300106885 and Tax returns
namely, Creditable Withholding Tax Returns with OR No. A00107 issued by PNB in the amount of
P26,990.28 and with OR No. A00161, issued by PNB in the amount of P16,620.00 were lost, and could
not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said documents.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019, at
Dipolog City.

JOSE C. BACOLCOL,JR
(Affiant)
TIN#102-336-913

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.

Doc No. _____ IVO M. MANDANTES

Page No. _____ NOTARY PUBLIC FOR ZN
Book No. ____ UNTIL 12-31-2019
Series of 2019 COMMISSION NO.ZDN-DPL-022-2018
ROLL NO. 65014
LAPU-LAPU ST. DIPOLOG CITY
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, NITA D. CAIS, of legal age, Filipino, single, a resident of Gunyan, SIayan, Zamboanga del Norte after
having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of a Philippine Passport issued by the Department of Foreign Affairs.

That in September 2019, while I was at our house in Siayan together with my child and I kept my
passport with my bag, however, my child came to possess it and used it as a toy. Then my child went
outside where the said passport was probably thrown away and lost. Then, when I inspected my bag I
found out that my passport was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said passport.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019, at
Dipolog City.

NITA DALANGON CAIS

(Affiant)
Philhealth ID#14-201604028-0

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.
Doc No. _____ IVO M. MANDANTES
Page No. _____ NOTARY PUBLIC FOR ZN
Book No. ____ UNTIL 12-31-2019
Series of 2019 COMMISSION NO.ZDN-DPL-022-2018
ROLL NO. 65014
LAPU-LAPU ST. DIPOLOG CITY

Doc. No.__
Page No.__
Book No.__
Series of 2019
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ROSARIO T. LACAYA, of legal age, Filipino, widow, a resident of San Antonio, Polanco, Zamboanga
del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of a document known as Extrajudicial Settlement of the Estate of
Ricardo Lacaya notarized by Atty Eulogio L. Lagudas,Jr. per Doc. No.4423, Page No. 74, Book No.35,
Series of 2018.

That on May 27, 2019, while I was trying to look for my said document from my file folder, then I
found out that the said document was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said Extrajudicial Settlement of the Estate of Ricardo Lacaya
document.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019, at
Dipolog City.

ROSARIO T. LACAYA
(Affiant)
OSCA ID#18-03887 Polanco, Zamboanga del Norte
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.

Doc No. _____ IVO M. MANDANTES

Page No. _____ NOTARY PUBLIC FOR ZN
Book No. ____ UNTIL 12-31-2019
Series of 2019 COMMISSION NO.ZDN-DPL-022-2018
ROLL NO. 65014
LAPU-LAPU ST. DIPOLOG CITY
Doc. No.__
Page No.__
Book No.__
Series of 2019

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ANASTACIO B. BANGCALE, of legal age, Filipino, married, a resident of Anastacio, Polanco,

Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am Chairman of the Board of Directors of Polanco Water District and as Chair, I was issued a
cellular phone identified as Oppo A37 color Black.

That on September 27, 2019, while I was checking my cellular phone from my pants, I found out that
the said cellular phone was lost it may be because my pants was already worn out; I tried to contact
said cellular phone but the device could not be reached, and thus could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said cellular phone.
IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019, at
Dipolog City.

ANASTACIO B. BANGCALE
(Affiant)
Driver’s License#J01-05-003736
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.

Doc No. _____ IVO M. MANDANTES

Page No. _____ NOTARY PUBLIC FOR ZN
Book No. ____ UNTIL 12-31-2019
Series of 2019 COMMISSION NO.ZDN-DPL-022-2018
ROLL NO. 65014
LAPU-LAPU ST. DIPOLOG CITY

Doc. No.__
Page No.__
Book No.__
Series of 2019
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, MARIA RIO A. NAGUIT, of legal age, Filipino, single, a resident of Dawo, Dapitan City, Zamboanga del
Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of a Pocket Wifi device issued by Globe Telecom under a Postpaid
Plan.

That on September 28, 2019, while I was checking out at the hotel in Zamboanga City, I found out that
the Globe Pocket Wifi was lost, I tried to contact the hotel but the device was already lost, and could
not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said Globe Pocket Wifi device under Globe Telecom
Postpaid Plan.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019, at
Dipolog City.

MARIA RIO A. NAGUIT

(Affiant)
ID#__________________________
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2019
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, CELSO D. MAGBARIL,JR, of legal age, Filipino, single, a resident of Isis, Polanco, Zamboanga del
Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of an official receipt/Certificate of Estate Tax Payment of Victoria P
Est of Harris because I am one of the buyers of one of the estates of the deceased .

That sometime year 2018, while I was trying to look for the said receipt/certificate from my file folder,
I found out that the receipt/certificate was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said official receipt/certificate of estate tax payment of
Victoria P Est of Harris

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019, at
Dipolog City.

CELSO D. MAGBARIL,JR.
(Affiant)
ID#__________________________
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2019
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, MARIGEL E. ESTRADA, of legal age, Filipino, a resident of Obay, Polanco, Zamboanga del Norte after
having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of a Driver’s License, Voters ID, and other documents put inside my
wallet.

That on September 17, 2019, while I was trying to look for my wallet containing all those IDs, then I
found out that the said wallet was stolen thus lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said Driver’s License, Voters ID, and other documents.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019, at
Dipolog City.

MARIGEL E. ESTRADA
(Affiant)
CTC #CCI201816886399-Obay,Polanco,ZN dated 9/16/2019
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2019
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, WENDELINA I. ACAIN, of legal age, Filipino, widow, a resident of Lamao, Liloy, Zamboanga del Norte
after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of a document known as Deed of Absolute Sale notarized by Atty Ivo
M. Mandantes per Doc. No.867, Page No. 79, Book No.II, Series of 2019.

That on August 2, 2019, while I was trying to look for my said document from my file folder, then I
found out that the said Deed of Absolute Sale document was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said Deed of Absolute Sale document.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019, at
Dipolog City.

WENDELINA I. ACAIN
(Affiant)
OSCA ID#1236-Liloy, Zamboanga del Norte
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2019
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, RAYMOND L. RUEDAS, of legal age, Filipino, married, a resident of Minaog, Dipolog, Zamboanga del
Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of a claim stub for my National Certificate II-Cookery issued by
Technical Education and Skills Development Authority(TESDA) .

That on August 2, 2019, while I was trying to look for my said claim stub from my file folder, then I
found out that my claim stub was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said claim stub and for issuance of my NC II Certificate.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019, at
Dipolog City.

RAYMOND L. RUEDAS
(Affiant)
Passport#C1332867
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2019
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, DANILO Q. MONTES, of legal age, Filipino, married, with office address of Quezon Ave., Barra,
Dipolog City, Zamboanga del Norte after having been duly sworn in accordance with law, hereby
depose and state:

That I am the business owner of a tailoring business with Business Name “ Danny’s Tailor” situated at
Quezon Ave., Barra, Dipolog City. The said business is registered at City of Dipolog and was issued a
Business Permit and Business Plate.

That in the first week of September, 2019, while I was trying to arrange several office documents and
locating the said Business Plate, but it was lost and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said Business Plate.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019, at
Dipolog City.

DANILO Q. MONTES
(Affiant)
ID#____________________

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2019
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, JUDITH G. JARMIN, of legal age, Filipino, a resident of Polanco, Zamboanga del Norte after having
been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of a passbook issued by First Consolidated Bank(FCB)- Dipolog City
Branch.

That on August 2, 2019, while I was trying to look for my said passbook from my file folder, then I
found out that my passbook was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said FCB Passbook.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019, at
Dipolog City.

JUDITH G. JARMIN
(Affiant)
PRC ID#0774731
With Photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2019
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ARNYL C. ALFORQUE, of legal age, Filipino, married, a resident of Maria Cristina, Dapitan City,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am the mother of JAN RAPHAEL C. ALFORQUE, a minor, who is a holder and possessor of an
Automated Teller Machine(ATM) card issued by Land Bank of the Philippines(LBP)-Dipolog City
Branch.

That last week of August, 2019, while my son was going home, he discovered that the LBP ATM card
was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said LBP ATM card and thereafter requesting replacement
thereon.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019, at
Dipolog City.
 ARNYL C. ALFORQUE
(Affiant)
PRC ID#0586752

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2019

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, JUNREY S. BESTES, of legal age, Filipino, with office address of Estaka, Dipolog City, Zamboanga del
Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am the Manager of DES STRONG MOTORS, INC. Dipolog City Branch with registered address of
National Highway Estaka, Dipolog City. The said business is registered at Bureau of Internal Revenue
and was issued a Certificate of Registration.

That in the first week of May, 2019, while the personnel were trying to arrange several office
documents and locating the said BIR Certificate of Registration, but it was lost and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said Original Copy of Certificate of Registration.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019, at
Dipolog City.
 JUNREY S. BESTES
(Affiant)
SSS#10-0888407-8

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2019

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, MARIBETH ELUMBARING BUSICO, of legal age, Filipino, married, a resident of Sicayab, Dipolog City,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am the spouse of RONALD TAN BUSICO, graduate of Bachelor of Science in Accountancy at
Saint Vincent’s College in October 1999. He was a holder and possessor of a Diploma issued by Saint
Vincent’s College.

That in the first week of September, 2019, while I was trying to locate the said diploma, but it was lost
and could not be found; I even called him to locate his diploma but he could not find it also;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said Diploma of my spouse Ronald T. Busico.
IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019, at
Dipolog City.

MARIBETH E. BUSICO
(Affiant)
SSS ID#33-5567046-7

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2019

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, NURHAMIN S. NUR, of legal age, Filipino, married, a resident of Minaog, Dipolog City, Zamboanga
del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of a Driver’s License with Official receipt issued by Land
Transportation Office,Dipolog City.

That in the first week of July, 2019, while I was trying going home, then I found out that my wallet
containing my driver’s license was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;
As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said driver’s license.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019, at
Dipolog City.

NURHAMIN S. NUR
(Affiant)
DL#J0616000732

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2019

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, EUGENIA R. OBIDO, of legal age, Filipino, single, a resident of Obay, Polanco, Zamboanga del Norte
after having been duly sworn in accordance with law, hereby depose and state:
That I am a holder and possessor of a passbook issued by Micro-Entrepreneurs Multi-Purpose
Cooperative(MEMPCO), Dipolog City Branch.

That on August 2, 2019, while I was trying to look for my said passbook from my file folder, then I
found out that my passbook was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said MEMPCO Passbook.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019, at
Dipolog City.

EUGENIA R. OBIDO
(Affiant)
DSWD PPPP#097210020-9998-39479

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2019

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, HENRY OTUD, of legal age, Filipino, a resident of Pob. North, Polanco, Zamboanga del Norte after
having been duly sworn in accordance with law, hereby depose and state:
That I am a holder and possessor of a Driver’s License with Official receipt issued by Land
Transportation Office,Dipolog City.

That in the first week of July, 2019, while I was trying going home, then I found out that my wallet
containing my driver’s license was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said driver’s license.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019, at
Dipolog City.

HENRY OTUD
(Affiant)
Papua New Guinea License#1224984 valid until 12/6/2022

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2019

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x
 AFFIDAVIT OF LOSS

I, NESTOR A. BATABAT, of legal age, Filipino, single, a resident of Pob. North, Polanco, Zamboanga del
Norte after having been duly sworn in accordance with law, hereby depose and state:

That I was a business owner registered at BIR, Pampanga. That as an owner of a business, I
maintained books of accounts, certificate of registration, official receipts, Notice to the Public/Ask for
Receipt, BIR Form 1905, Municipal Retirement Certification and Barangay Closure, Annual Income Tax
Returns, Inventoryt List of Unused Invoices/Receipts, and POS Permits;

That sometime June 2012, I relocated in Zamboanga del Norte resulting to closure of my business. I
left the mentioned documents and files in Pampanga. Now I tried to locate it but were lost, and could
not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said BIR documents/files.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019, at
Dipolog City.

NESTOR A. BATABAT
(Affiant)
TNI#933782523

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2019
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ROSARIO SHARON S. ORTEGA, of legal age, Filipino, married, a resident of Mibang, Sta. Isabel,
Dipolog City, Zamboanga del Norte after having been duly sworn in accordance with law, hereby
depose and state:

That I am a possessor of an official receipt issued by MLhuillier for a pawned jewelry with Receipt
No.PTN0553-2015-00184.

That on August 30, 2019, I received a call that my pawned jewelry is due today so I tried to locate the
receipt but it was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said official receipt of MLhuillier.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019, at
Dipolog City.

ROSARIO SHARON ORTEGA

(Affiant)
PRC ID#0233877

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2019
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, MANNY T. ALAJAS, of legal age, Filipino, single, a resident of Pob. South, Polanco, Zamboanga del
Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am an Accounts Monitoring Staff of Benevolent Care Program Association, Inc. That as a staff, I
am in possession of official receipts amounting to three(3) stubs with each stub has 50 receipts;

That on June 30, 2019, I was traveling in Dipolog City with these stubs, I found out that the stubs were
lost, and could not be found. I believe that I have lost the stubs at Dipolog Boulevard, Dipolog City
while I was eating in one of the stands of balut vendor at Dipolog Boulevard;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said stubs of Benevolent Care Program Association, Inc

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019, at
Dipolog City.

MANNY T. ALAJAS
(Affiant)
VIN#7210-0011A-G0290MTA10000

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2019
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, FRENCITO G. PASIGNA, of legal age, Filipino, married, a resident of VCH, Obay, Polanco, Zamboanga
del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am the attorney-in-fact of Honorata M. Villamin, the only surviving heir of Pastor Mabilog,
married to Aniceta P. Mabilog who the registered owner of parcel of land covered OCT No.RP-
156(1921) situated at Dansalan, Labason, Zamboanga del Norte, for the processing of titling of the
said land.

That upon endorsement of the notarized extrajudicial settlement/partition of the estate of Pastor
Mabilog to me, I was informed that the Survey Plan with Survey Plan No. Psd-110587 and Technical
Descriptions of the said parcel of land were lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said Survey Plan and Technical Descriptions of 8 Lots and
for reproduction of the same.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019, at
Dipolog City.

FRENCITO G. PASIGNA
(Affiant)
OSCA ID#18-03592 Polanco,ZN

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2019
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ANGELICA MANON-OG PALIOTA, of legal age, Filipino, single, a resident of Lugdungan, Dipolog City,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of a Philippine Passport issued by the Department of Foreign Affairs.

That on August 18, 2019, while I was aboard in a tricycle with my bag containing my passport, I found
out that my passport was lost, and could not be found. It is believed that the said passport was lost
while I was traveling;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said passport.
IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019, at
Dipolog City.

ANGELICA M. PALIOTA
(Affiant)
PRC ID#0173941 valid until 3/31/2020

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2019

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, MARK E. ALFAR, of legal age, Filipino, a resident of Pob. Alto, Sergio Osmeña, Zamboanga del Norte
after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of a Passport issued by Department of Foreign Affairs, Voter’s
Certification, Employment Certification, NBI Clearance, Certificate of Live Birth issued by PSA,
Transcript of Records from my school and Good Moral Character and Form 1A issued by PSA.

That on August 26, 2019, while I was going home with my folder containing the abovesaid documents
however when I crossed the roaring river I lost the said folder and was taken. Due to heavy rain and
roaring river, the folder could be retrieved, and could not be found;
That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said documents and thereafter requesting replacement
thereon.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019, at
Dipolog City.

MARK E. ALFAR
(Affiant)
Municipality of Sergio Osmeña, ZN Employees ID#18-JO-840

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2019

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, JHONNA P. BAS, of legal age, Filipino, married, a resident of Sangkol, Dipolog City, Zamboanga del
Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of an Automated Teller Machine(ATM) card issued by Development
Bank of the Philippines(DBP)-Dipolog City Branch.
That on August 26, 2019, while I was trying going home, then I found out that my card holder
containing my ATM was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said DBP ATM card and thereafter requesting replacement
thereon.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019, at
Dipolog City.

JHONNA P. BAS
(Affiant)
ZNHS ID#ZNHS-E14136

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2019

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT
I, ROSEFELY A. OMANDAM, of legal age, Filipino, married, a resident of San Isidro, Gutalac,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose
and state:

That I am the caretaker of the house of late MAYOR MARIANO DELOS REYES CANDELARIA SR.

That I was reporter of the lost firearms owned and registered in the name of above-named
Mariano D. Candelaria Sr. which are as follows:

MAKE KIND CALIBER SERIAL NO.

ELISC HPRFL 556 1322891

TRUS PISTL 9MM TVK05306

NORIN PISTL 22 951674

CARBN HPRFL 30 2840859

COLT PISTL 45 958841

That on September 16, 2015 at about 7 in the morning, I went to the house of Candelaria, Sr
because the latter was hospitalized at that time I found out that the house was in disarray
which upon inspection and checking the first three(3) firearms were lost and could not be
located anymore;

That on December 1, 2015, during the birthday of late Candelaria,Sr., he declared that his
firearms which identified as the last two(2) firearms abovementioned was lost from the coffers
where he kept it and he made declarations in front of his family and us. He further mentioned
he held the said firearms in year 1998 but thereafter lost it;

That despite effort to recover the same but it was naught.

Hence, I considered it as totally lost by Mariano Candelaria, Sr.’s family after his demise.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements
and for the purpose of attesting to the loss of the said firearms.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019,
at Dipolog City.

ROSEFELY A. OMANDAM

(Affiant)

ID#________________________

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.

Doc. No.__
Page No.__
Book No.__
Series of 2019
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, EVA O. SALONOY, of legal age, Filipino, married, a resident of Pob.North, Polanco,

Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose
and state:

That I am one of the compulsory heirs of Bienvenido Ocupe, registered owner of a parcel of
land known as Lot No.4027 covered by OCT No. O-457 located at Poblacion North, Polanco,
Zamboanga del Norte and a parcel of land known as Lot 4031-B covered by TCT No.T-39219
located at Pob. North, Polanco, Zamboanga del Norte.

That sometime in January 2019 my brother Orlando Ocupe, who was the keeper of land titles
in the name of our father, died. Then I checked my file folder of documents where Orlando
always kept all documents like title of land, I found out that owner’s duplicate copy of the
above said titles was lost, and could not be found;

That despite effort to recover the same but it was naught.

Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements
and for the purpose of attesting to the loss of the said Transfer Certificate Title No.T-39219
and Original Certificate of Title No.O-457.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019,
at Dipolog City.
 EVA O. SALONOY

(Affiant)

OSCA ID#18-03992-Polanco, Zamboanga del Norte

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.

Doc. No.__
Page No.__
Book No.__
Series of 2019

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, GLECERIO A. FERRAREN, of legal age, Filipino, married to Concepcion J. Ferraren, a resident

of Quezon Ave., Potol, Dapitan City, Zamboanga del Norte after having been duly sworn in
accordance with law, hereby depose and state:

That I am one of the compulsory heir of Eutiquio Ferraren,a registered owner of a parcel of
land known as Lot No.303 covered by TCT No. (T-18444)1413 located at Dawo(now), Dapitan
City, Zamboanga del Norte.

That sometime in April, 2019, while I was checking my file folder of documents where I always
keep all documents like title of land, I found out that owner’s duplicate copy of the said
title ,being the custodian of the family,was lost, and could not be found;

That despite effort to recover the same but it was naught.

Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements
and for the purpose of attesting to the loss of the said Transfer Certificate Title No.(T-
18444)1413.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019,
at Dipolog City.
 GLECERIO A. FERRAREN

(Affiant)

ID#____________________________

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.

Doc. No.__
Page No.__
Book No.__
Series of 2019

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS
I, SHEENA MAE QUIÑANOLA-TABUDLONG, of legal age, Filipino, married, a resident of Polanco, Zamboanga
del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of employment contracts with the following companies:

COMPANY NAME EMPLOYMENT PERIOD POSITION

1.ARIANA HOTEL, INC. July 9, 2014- October 15, Executive Assistant to the President
2014

2.JP MORGAN CHASE & CO. February 21, 2013-October Financial Specialist(Canada Card
9, 2013 Member Services)

3.MOEVENPICK HOTEL MACTAN 1. April 29, 2011-November Sales Executive

ISLAND 18, 2011

2.February 29, 2012-

September 12, 2012

4.PLANTATION BAY RESORT & May 17, 2010-December Sales Executive

SPA 18, 2010

That I have filed my employment contracts for the abovesaid jobs at our old house, however, my family
relocated to another place of residence and then I found out that I left the said file to our former house as
such I now considered it as lost, and could not be found;That despite effort to recover the same but it was
naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for the
purpose of attesting to the loss of the said employment contracts.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019, at Dipolog City.

SHEENA MAE QUIÑANOLA-TABUDLONG

(Affiant)
UMID #CRN-0111-8177060-1

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2019

Book No.__
Series of 2019

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ELMER O. BARTE, of legal age, Filipino, a resident of Polanco, Zamboanga del Norte after having
been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of a Driver’s License with Official receipt issued by Land
Transportation Office,Dipolog City.

That on August 19, 2019, while I was trying going home, then I found out that my wallet containing
my driver’s license was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said driver’s license.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019, at
Dipolog City.
 ELMER O. BARTE
(Affiant)
ID#______________________

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.
Doc. No.__
Page No.__

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ANGELITA L. NAKAGAWA, of legal age, Filipino, married, a resident of Sicayab Bocana, Dapitan City,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of a Driver’s License with Official receipt issued by Land
Transportation Office,Dipolog City.

That on August 20, 2019, while I was trying to renew my driver’s license, then I found out that the
official receipt of my driver’s license was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said official receipt of my driver’s license.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019, at
Dipolog City.

ANGELITA L. NAKAGAWA
(Affiant)
Driver’s License#J01-08-001572

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2019
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, VIRGINIA MAGTACA UNSON, of legal age, Filipino, married, a resident of Brgy. Sianib, Polanco,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of a Diploma as a graduate of high of Zamboanga del Norte National
High School in the year 1983.

That sometime August 2019, while I was scanning and checking my file folder containing my Diploma
as graduate of high school, but I could not locate it. Then I found out it was lost, and could not be
found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said High School Diploma and to attest that I graduated high
school.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019, at
Dipolog City, Philippines.

VIRGINIA MAGTACA-UNSON
(Affiant)
VIN#7210-0094A-A1363VMU20000

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2019
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, GINA B. MUTIA, of legal age, Filipino, married, a resident of Langatian, Roxas, Zamboanga del Norte
after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor/owner of a Nokia cellphone unit under postpaid plan of Globe
Telecom.

That on August 15, 2019 at about 5pm in Pagadian City, while I was at my car parking at Gaisano Mall,
I suddenly felt that something was missing. Later I found out that my cellphone was lost, and could
not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said cellular phone unit.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019, at
Dipolog City.

GINA B. MUTIA
(Affiant)
UMID ID#CRN-0010-0552807-8

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2019

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, HONEYLETTE A. BALUCOS, of legal age, Filipino, single, a resident of Sumbayaw, Lapayan Baja,
Polanco, Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose
and state:

That I am a holder and possessor of a Philippine Passport issued by the Department of Foreign Affairs,
Social Security System(SSS) ID issued by SSS, my Petros Paulos Food Products company ID, and
Philhealth ID issued by Philippine Health Insurance Corporation.
That on August 15, 2019 at about 4am, while I was driving my motorcycle I accidentally slipped and
during the process my pouch containing my said valid IDs was lost, then later I found out that my
passport,SSS ID, my company ID and Philhealth ID were lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said passport, SSS ID and Philhealth ID.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019, at
Dipolog City.

HONEYLETTE A. BALUCOS
(Affiant)
Dipolog City Health Office Certificate No. 19-710

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2019

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, MARY ANN ALMIROL ANDALAHAO, of legal age, Filipino, single, a resident of Don Jose Aguirre,
Manukan, Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose
and state:

That I am a holder and possessor of a Unified Multi-purpose ID(UMID) card with No. CRN-021-1107-
8824-0.

That sometime November 2016, while I was going to the cemetery to visit my dead loveones I lost my
wallet that contained my UMID card with Union Bank as the depository bank. I waited for someone
who might find it but nobody approached. Thus, I considered my said UMID card as lost, and could
not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said UMIC ID card.
IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019, at
Dipolog City.

MARY ANN ALMIROL ANDALAHAO

(Affiant)
UMID ID#CRN-021-1107-8824-0

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2019

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ERNESTO J. ESCABARTE, of legal age, Filipino, married, a resident of Lot 15, Lot 14, Victoria Country
Homes Subd., Obay, Zamboanga del Norte after having been duly sworn in accordance with law,
hereby depose and state:

That I am a holder and possessor of a firearm, described as follows:

Make:Colt Kind:Pistl FA Lic.No.:896843I1679724

Caliber:45 Serial No.579155 Control No.:I-E0064596

That sometime December 2018, while I was in the Philippines having a vacation so I intended to
process the renewal of my said firearm. However, upon checking the said firearm where I kept it, I
could not locate it. The reason could be was that I was having a renovation of my house and I do not
know if one of the workers stole it. Thus, I considered it as lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said firearm.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019, at
Dipolog City.

ERNESTO J. ESCABARTE
(Affiant)
Firearm License Card Control No.I-E0064596

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2019

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, DENNIS AGAPAY ESIG, of legal age, Filipino, single, a resident of Del Pilar St., Estaka, Dipolog City,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of a Social Security System(SSS) Identification card.

That on August 2, 2019, while I was trying to look for my said SSS ID from my file folder, I then
remembered that I have not received my SSS ID delivered to my previous company in Zamboanga
City. Thus, I found out that my SSS ID was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said SSS ID.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019, at
Dipolog City.

DENNIS AGAPAY ESIG

(Affiant)
Driver’s License#J01-18-007785 valid until 6/12/23

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2019
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ROSELIA J. YBAÑEZ, of legal age, Filipino, married, a resident of New Sicayab, Polanco, Zamboanga
del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of a passbook issued by 1st Valley Bank, Dipolog.

That on August 2, 2019, while I was trying to look for my said passbook from my file folder, then I
found out that my passbook was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said 1st Valley Bank Passbook.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019, at
Dipolog City.

ROSELIA J. YBAÑEZ
(Affiant)
TIN#946-807-806

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2019

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, FELIX J. PENOLLERA, of legal age, Filipino, married, a resident of Bandera, Polanco, Zamboanga del
Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of a Professional Driver’s License with License No. J01-07-002621.
That on August 2, 2019, while I was trying to look for my Driver’s License from my wallet, then I found
out that my Driver’s License was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said driver’s license.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019, at
Dipolog City.

FELIX J. PENOLLERA
(Affiant)
Driver’s License#J01-07002621

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2019

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, NOREEN RAMONA O. GRANCAPAL, of legal age, Filipino, married, a resident of Lalawan,Dicayas,

Dipolog City, Zamboanga del Norte after having been duly sworn in accordance with law, hereby
depose and state:

That I am a holder and possessor of an Automated Teller Machine(ATM) card issued by the Land Bank
of the Philippines with savings account No.0527-2149-98.

That on August 2, 2019, while I was trying to transact and withdraw from my ATM, then I found out
that my ATM was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said Landbank ATM card.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019, at
Dipolog City.
 NOREEN RAMONA O. GRANCAPAL
(Affiant)
PCA ID#2013-07

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2019

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, MERIDION B. SAPALLEDA, of legal age, Filipino, married, a resident of Aseniero, Dapitan City,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a barangay official of Brgy. Aseniero, Dapitan City and I was issued by the Barangay Aseniero
local government of a CIGNUS MV-85 handheld radio with Serial No.201208601570, Color: Military
Fatigue, Call Sign:DU9-8342.

That on July 22, 2019, at around 7pm, while I was on duty and responded on incident of alleged
robbery at the barangay, then I found out that the said handheld radio was lost, and could not be
found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.
As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said handheld radio.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019, at
Dipolog City.

MERIDION B. SAPALLEDA
(Affiant)
DILG ID#097201003-07

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2019

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, EMELITA PADEN LIMBAGA, of legal age, Filipino, married, a resident of Dohinob, Roxas, Zamboanga
del Norte after having been duly sworn in accordance with law, hereby depose and state:
That I am a holder and possessor of an ATM card issued by the Land Bank of the Philippines, a PRC
license issued by PRC, Unified Multi-purpose ID(UMID) card with no.CRN-006-0041-0377-4, Voter’s ID
and SSS ID.

That on June 26, 2019, while I was at Upper Irasan Elementary School teaching my students, then I
found out that my bag was stolen and thus lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost. That
the said bag contained the abovementioned items namely Landbank ATM card, PRC ID, UMID ID,
Voter’s ID, SSS ID.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said Landbank ATM card, PRC ID, UMID card, Voter’s ID, SSS
ID and hereby utilized this affidavit to replace the previously mentioned cards

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019, at
Dipolog City.

EMELITA PADEN LIMBAGA

(Affiant)
UMID #CRN-006-0041-0377-4

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2019

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, RINALYN SABANAL GALLEPOSO, of legal age, Filipino, married, a resident of East Poblacion,
Manukan, Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose
and state:

That I am a holder and possessor of a Social Security System Identification Card issued by the Social
Security System(SSS).

That sometime third week of July, 2019, while I was inquiring my SSS ID, I was informed that it was
already released but I have not received it, then I found out that my SSS was lost, and could not be
found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.
As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said SSS ID.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019, at
Dipolog City.

RINALYN SABANAL GALLEPOSO

(Affiant)
Postal ID#PRNM83170592983P

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2019

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, LUZVIMINDA BULAGAO LUMOGON, of legal age, Filipino, single, a resident of Mamawan, Gutalac,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of a Philippine Passport issued by the Department of Foreign Affairs.

That sometime third week of November, 2015, while I was checking my bag, I found out that my
passport was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said passport.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019, at
Dipolog City.

LUZVIMINDA BULAGAO LUMOGON

(Affiant)
Barangay ID Mamawan Gutalac,ZN #F00181

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2019

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, JHORLIE T. SAING, of legal age, Filipino, married, a resident of Galas, Dipolog City, Zamboanga del
Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of a LTO issued Official Receipt No.1417024313 for motor vehicle
with CR No. 313888223;

That sometime in July, 2019, while I was checking my wallet, I found out that my official receipt was
lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said official receipt.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019, at
Dipolog City.

JHORLIE T. SAING
(Affiant)
ID#_____________________

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2019
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, JULIET M. AGEAS, of legal age, Filipino, married, a resident of Sipaloc, Sibutad, Zamboanga del Norte
after having been duly sworn in accordance with law, hereby depose and state:

That I am the daughter of ESTRELLA OPO MONDING, who died on August 6, 2014;

That before she died, she informed me that she was a member of Paglaum Multi-purpose
Cooperative- Calamba Branch, with address of Calamba, Misamis Occidental; That she applied for a
loan and she put a security for Building Investment Plan(which has a receipt);

That after she died I was looking for the receipt of her payment for Building Investment Fund of the
said cooperative, but it was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said receipt and to prove her membership of the Paglaum
Multi-purpose Cooperative and get her benefits or the refund.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019, at
Dipolog City.

JULIET M. AGEAS
(Affiant)
TIN#456-980-655

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2019
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, MAGDALENA G. EGUIA, of legal age, Filipino, married, a resident of Brgy Uno, Katipunan,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of a LTO issued Driver’s License;

That sometime in July, 2019, while I was checking my wallet, I found out that my driver’s license was
lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said Driver’s License.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019, at
Dipolog City.

MAGDALENA G. EGUIA
(Affiant)
Driver’s License#J01-85-001599

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2019

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x
 AFFIDAVIT OF LOSS

I, HENRY Z. AVES, of legal age, Filipino, married to Angelita Pilapil, a resident of Isis, Polanco,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose
and state:

That I am a registered owner of a parcel of land known as Lot 10-D covered by TCT No. T-
85064 located at Isis, Polanco, Zamboanga del Norte.

That sometime in April, 2019, while I was checking my file folder of documents where I always
keep all documents like title of land, I found out that owner’s duplicate copy of the said title
was lost, and could not be found;

That despite effort to recover the same but it was naught.

Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements
and for the purpose of attesting to the loss of the said Transfer Certificate Title No.T-85064.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019,
at Dipolog City.

HENRY Z. AVES

(Affiant)

ID#_______________________________

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.

Doc. No.__
Page No.__
Book No.__
Series of 2019

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF EXPLANATION
I, NIMLA OCAY SABANAL, of legal age, Filipino, single, a resident of East Poblacion, Manukan,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose
and state:

That I was an applicant of a Philippine Passport which was issued to me and to my name by
Department of Foreign Affairs. However, upon approval and issuance, I failed to claim my
passport from DFA due to the reason that I was sick for a time and I lost my claim slip;

That, thereafter, I re-applied for a passport and I mistakenly failed to declare and disclose that
I had a previous application for passport which remains unclaimed;

That, I honestly and in good faith applied for passport so that I could a new passport and could

travel abroad;

As such, I am executing this Affidavit of Explanation to attest to the truth of the foregoing
statements and for the purpose of re-issuance/reclaiming my passport from DFA.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019,
at Dipolog City.

NIMLA OCAY SABANAL

(Affiant)
UMID ID#CRN-0111-8118950-6

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2019

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, EDILLO C. DIVINAGRACIA, of legal age, Filipino, single, a resident of Anastacio, Polanco, Zamboanga
del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of a LTO issued Driver’s License;

That on July 19, 2019, while I was checking my bwallet, I found out that my driver’s license was lost,
and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.
As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said Driver’s License.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019, at
Dipolog City.

EDILLO C. DIVINAGRACIA
(Affiant)
Philhealth ID#08-026410295-6

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2019

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ELOISA H. RUIZ, of legal age, Filipino, married, a resident of Leonor Rivera St., Sta. Cruz, Dapitan City,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of a LTO Certificate of Registration and updated Official Receipt for
the vehicle I own which has a File No.130100000804067, with Plate No. NDG 5720;

That sometime third week of May, 2019, while I was checking my bag, I found out that Certificate of
Registration and Official Receipt were lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said Certificate of Registration and Official Receipt.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019, at
Dipolog City.

ELOISA H. RUIZ
(Affiant)
 ID#________________________

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2019

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, MARK MICHAEL D. LAURQUE, of legal age, Filipino, married, a resident of Poblacion North, Polanco,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of a Philippine Passport issued by the Department of Foreign Affairs.

That sometime third week of May, 2019, while I was checking my bag, I found out that passport was
lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said passport.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019, at
Dipolog City.

MARK MICHAEL D. LAURQUE

(Affiant)
PDL#J01-03-040871

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2019
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT

I, FRANZ O. TRIAMBULO, of legal age, Filipino, married, a resident of Turno, Dipolog City,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose
and state:

That I am the registered of a motor vehicle, Toyota Hilux with MV File No.1301-00000700979,
with Certificate of Registration No. 254793464.

That since year 2017, I have not availed and renewed a comprehensive insurance coverage for
the said motor vehicle registered under my name;

As such, I am executing this Affidavit to attest to the truth of the foregoing statements and for
legal purposes it may serve.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019,
at Dipolog City.

FRANZ O. TRIAMBULO
(Affiant)
ID#____________________

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2019
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF EXPLANATION

I, MARITES A. DELOS REYES, of legal age, Filipino, single, a resident of Madison Country Homes,
Dicayas, Dipolog City, Zamboanga del Norte after having been duly sworn in accordance with
law, hereby depose and state:

That I am applicant of a Philippine Passport which was issued to me and to my name by

Department of Foreign Affairs. However, upon approval and issuance, I failed to claim my
passport from DFA-Zamboanga City due to the reason that my mother was sick in Davao City
and I needed to attend to her welfare during the period of her sickness;

That, thereafter, I needed to temporarily live in Davao City and took care of my sickly mother
and could not go to Zamboanga City and claim my passport;

As such, I am executing this Affidavit of Explanation to attest to the truth of the foregoing
statements and for the purpose of re-issuance/reclaiming my passport from DFA.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019,
at Dipolog City.

MARITES A. DELOS REYES

(Affiant)
VIN#72020208AI1984MAD20000

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2019
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, EMMA A. MUTIA, of legal age, Filipino, married, a resident of De Oro, Olingan, Dipolog City,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose
and state:

That I am the owner, together with my husband, of a parcel of land with Lot No. 2122-F,
covered by Transfer Certificate of Title No.T-31541 located at Olingan, Dipolog City.

That the said parcel of land has an improvement which is a residential building.

That on July 4, 2019, a portion of the above-said house was accidentally consumed by fire;

That the total estimated value of the lost portion of the building has an estimated cost of
P4,687,301.48.

That despite effort to recover the same during the accidental fire but it was naught. Hence, I
considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements
and for the purpose of attesting to the loss of the said improvement.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019,
at Dipolog City.

EMMA A. MUTIA
(Affiant)
ID#____________________________

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2019
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, KENNETH E. REGENCIA, of legal age, Filipino, single, a resident of Poblacion, Sibutad, Zamboanga del
Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of Honorable Dismissal and Good Moral Character documents issued
by Saint Vincent’s College, Dipolog City.

That sometime third week of June, 2019, while I was checking my bag, I found out that said document
was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said documents.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019, at
Dipolog City.

KENNETH E. REGENCIA
(Affiant)
Driver’s License#J01-16-002886

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2019
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, GLENDA R. DEL VALLE, of legal age, Filipino, married, a resident of Purok Maalagaron, Turno,
Dipolog City, Zamboanga del Norte after having been duly sworn in accordance with law, hereby
depose and state:

That I am a holder and possessor of a Client’s Card issued by Rural Bank of Liloy with office address at
Pinan, Zamboanga del Norte.

That sometime third week of April, 2019, while I was checking my bag, I found out that the said
client’s card was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said client’s card.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019, at
Dipolog City.

GLENDA R. DEL VALLE

(Affiant)
VIN#7202-0201A-F0560GRD20000-3

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2019

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, EMMA A. MUTIA, of legal age, Filipino, married, a resident of De Oro, Olingan, Dipolog City,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose
and state:
That I am the owner of house located at Olingan, Dipolog City.

That on July 4, 2019, a portion of the above-said house was accidentally consumed by fire;

The said room contained the following personal properties:

One(1) Unit Panasonic Airconditioning Unit worth P117,000.00

One(1) Unit Bedroom Set with Foam worth P85,000.00
One(1) Unit Sony TV and Home System worth P100,000.00
Three(3) piece Chair Set worth P85,000.00
One(1) Set Table and Chair worth P85,000.00
One(1) Unit Lamp worth P7,000.00
One(1) Unit Dressing Table worth P40,000.00
Sixty(60) pieces Adidas Sneakers worth P540,000.00
Fifteen(15) pieces Onitsuka Tiger Sneakers worth P105,000.00
Twenty-five(25) Nike Sneakers worth P225,000.00
Fifteen(15) Underarmour Sneakers worth P120,000.00
Thirty(30) Sketchers Sneakers worth P90,000.00
Fifteen(15) Tory Burch Flats worth P225,000.00
Two(2) Tod’s Women’s Loafers worth P59,000.00
Two(2) Todsitems Men’s Loafers worth P70,000.00
Two(2) Cole Haan Women’s Shoes worth P22,000.00
One(1) Gucci Sneakers worth P26,500.00
One(1) Louis Vuitton Sneakers worth P41,000.00
Fifteen(15) Kate Spade Handbags worth P225,000.00
Ten(10) Tory Burch Handbags worth P250,000.00
One(1) Gucci Leather Bag worth P190,000.00
One(1) Gucci Canvas Bag worth P50,000.00
Three(3) Louis Vuitton Handbag worth P225,000.00
One(1) Gucci Belt worth P22,000.00
Two(2) Tory Burch Wallets worth P30,000.00
Seventy-five(75) Assorted Active Wear(pair) worth P375,000.00
Makeup worth P30,000
Perfumes worth P50,000.00
Sports Watches worth P75,000.00
Clothing worth P150,000.00
Accessories(Sunglasses, scarves and etc.) worth P60,000.00
Others items worth P15,000.00

That the total value/cost of all mentioned personal assets would worth P3,789,500.00.

That despite effort to recover the same during the accidental fire but it was naught. Hence, I
considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements
and for the purpose of attesting to the loss of the said items.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019,
at Dipolog City.
 EMMA A. MUTIA
(Affiant)
ID#____________________________

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2019
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ROY JUMAWAK DALMAN, of legal age, Filipino, married, a resident of North Curvada, Galas,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of a Philippine Passport issued by the Department of Foreign Affairs.

That sometime third week of May, 2019, while I was checking my bag, I found out that passport was
lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said passport.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019, at
Dipolog City.

ROY JUMAWAK DALMAN

(Affiant)
UMID#CRN-0010-0818342-3

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2019

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x
 AFFIDAVIT OF LOSS/NON-RECOVERY

I, CECILIA F. CATUBIG, of legal age, Filipino, widow, a resident of Isis, Polanco, Zamboanga del Norte
after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of an ATM Card issued by the Landbank with Account No.
0516325607.

That sometime third week of June, 2019, while I tried to recover my ATM card from another person,
the ATM card was not returned;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said ATM card.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019, at
Dipolog City.

CECILIA F. CATUBIG
(Affiant)
OSCA ID#18-02028,Polanco,ZN

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2019

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ROSEMARIE CASTILLON NANO, of legal age, Filipino, single, a resident of Lingasad, Polanco,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of a Philippine Passport issued by the Department of Foreign Affairs.

That sometime third week of May, 2019, while I was checking my bag, I found out that passport was
lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.
As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said passport.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019, at
Dipolog City.

ROSEMARIE CASTILLON-NANO
(Affiant)
NBI ID#C234GRSE68-DR141483
Valid May 16, 2020

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2019

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, DINDO C. DALMAN, of legal age, Filipino, married, a resident of Isis, Polanco, Zamboanga del Norte
after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of Official Receipt #1339720325 and CR from Land Transportation
Office for the motor vehicle with Plate No.090106 under my name.

That sometime third week of May, 2019, while I was checking my bag, I found out that OR was lost,
and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said OR.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019, at
Dipolog City.

DINDO C. DALMAN
(Affiant)
DL#J01-01-035822 UNTIL 9/27/2023

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2019

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, CLARITA V. REDILLAS, of legal age, Filipino, married, a resident of Isis, Polanco, Zamboanga del Norte
after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of OSCA(Senior Citizen’s) Identification Card.

That sometime third week of May, 2019, while I was checking the purse of my bag, I found out that
my OSCA ID was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said OSCA ID.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019, at
Dipolog City.

CLARITA V. REDILLAS
(Affiant)
ID#______________________

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2019
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, MAUREEN M. SILVA, of legal age, Filipino, married, a resident of Purok Rubia, Obay, Polanco,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of Unified Multi-purpose ID(UMID) card and PRC Identification Card .

That sometime third week of May, 2019, while I was checking the purse of my bag, I found out that
the purse including my UMID card and PRC ID was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said UMID card and PRC ID.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019, at
Dipolog City.

MAUREEN M. SILVA
(Affiant)
UMID#CRN-006-0052-4900-6

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2019

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS
I, ALVINO S. FLORES, JR, of legal age, Filipino, a resident of Aquino St., Biasong, Dipolog City,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of a Certificate of Registration with CR No279578585 issued by Land
Transportation Office.

That sometime in 2018, I was issued a TOP with No. 11076690 by LTO/other agency which I kept in
the folder, however I found out that the TOP was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said TOP.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019, at
Dipolog City.

ALVINO S. FLORES,JR
(Affiant)
ID#_____________________

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2019

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, RENO T. ALANO, of legal age, Filipino, a resident of Katipunan, Zamboanga del Norte after having
been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of a Certificate of Registration with CR No. 8253619-3 issued by Land
Transportation Office.

That sometime May, 2019, while I was checking the folders and file of the above-said CR, I found out
that the CR was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.
As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said Certificate of Registration.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019, at
Dipolog City.

RENO T. ALANO
(Affiant)
ID#_____________________

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2019

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, FE P. LOPEZ, of legal age, Filipino, married, a resident of Barra, Dipolog City, Zamboanga del Norte
after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of Voter’s Identification Card issued by Commission on Election.

That sometime May, 2019 at around 6 pm, while I was checking the folders and file of the above-said
ID, I found out that the voter’s ID was lost, and could not be found;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said voter’s ID.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019, at
Dipolog City.

FE P. LOPEZ
(Affiant)
ID#_____________________

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2019

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ARNEL B. CORNELIO, of legal age, Filipino, single, a resident of Mitimos, Rizal, Zamboanga del Norte
after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of PNP ID card, driver’s license card, Landbank ATM card, TIN ID
card, PTC of firearms and firearms license card, voter’s ID, official receipt from tonga’s and others.

That on May 31, 2019 at around 6 pm, after I conductied patrol at coastal barangays of Rizal,
Zamboanga del Norte, I found out that my wallet was lost, and could not be found;

That the said wallet contained my PNP ID card, driver’s license card, Landbank ATM card, TIN ID card,
PTC of firearms and firearms license card, voter’s ID, official receipt from tonga’s, cash estimated to
P800.00 and others;

That despite effort to recover the same but it was naught. Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for
the purpose of attesting to the loss of the said wallet and my PNP ID card, driver’s license card,
Landbank ATM card, TIN ID card, PTC of firearms and firearms license card, voter’s ID, official receipt
from tonga’s, and cash estimated to P800.00 .

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019, at
Dipolog City.

ARNEL B. CORNELIO
(Affiant)
ID#______________________

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.
Doc. No.__
Page No.__
Book No.__
Series of 2019
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, MHAR KIERBY LANGAMIN VARGAS, minor, Filipino, single, a resident of Purok Central,
Oilngan, Dipolog City, Zamboanga del Norte after having been duly sworn in accordance with
law, hereby depose and state:

That I am a holder and possessor of a Saint Vincent’s College Student Identification Card.

That sometime in March, 2019, while I was checking my bag where I always keep my
identification cards, I found out that my SVC identification card was lost, and could not be
found;

That despite effort to recover the same but it was naught.

Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements
and for the purpose of attesting to the loss of the said SVC ID.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019,
at Dipolog City.

MARIA LIBERTY L. VARGAS MHAR KIERBY L. VARGAS

(Affiant-Mother) (Affiant-Student)

ID#______________________

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.

Doc. No.__

Page No.__

Book No.__

Series of 2019

Republic of the Philippines. . . . . . )

Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, RODELEINE GRACE R. DELMO, of legal age, Filipino, single, a resident of Bagacayan, Galas,
Dipolog City, Zamboanga del Norte after having been duly sworn in accordance with law,
hereby depose and state:

That I am a holder and possessor of a Driver’s License issued by LTO.

That on May 21, 2019 in Cebu City, while I was checking my bag where I always keep my wallet
with identification cards, I found out that my wallet with my identification cards including
Driver’s License was lost, and could not be found;

That despite effort to recover the same but it was naught.

Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements
and for the purpose of attesting to the loss of the said Driver’s License.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019,
at Dipolog City.

RODELEINE GRACE R. DELMO

(Affiant)

ID#______________________

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.

Doc. No.__

Page No.__
Book No.__

Series of 2019

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, YULANDA B. MALIGRO, of legal age, Filipino, married, a resident of Galas, Dipolog City,
Zamboanga del Norte after having been duly sworn in accordance with law, hereby depose
and state:

That I am a holder and possessor of a Senior Citizen’s Identification Card with Control No.
14829 issued by OSCA-Dipolog City, DSWD.

That sometime in February, 2019, while I was checking my bag where I always keep my
identification cards, I found out that my Senior Citizen’s ID was lost, and could not be found;

That despite effort to recover the same but it was naught.

Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements
and for the purpose of attesting to the loss of the said Senior Citizen’s ID.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019,
at Dipolog City.

YULANDA B. MALIGRO

(Affiant)

OSCA ID#14829-Dipolog City

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.

Doc. No.__

Page No.__

Book No.__

Series of 2019

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x
AFFIDAVIT OF LOSS

I, NORBERTO C. BAGISPAS, of legal age, Filipino, married, a resident of Langatian, Zamboanga del Norte after having
been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of a Professional Regulation Commission(PRC) registration card as licensed professional
teacher issued by PRC.

That sometime in October, 2016, while I was checking my bag where I always keep my identification cards, I found out
that my PRC ID card was lost, and could not be found;

That despite effort to recover the same but it was naught.

Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for the purpose of
attesting to the loss of the said PRC ID.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 201_, at Dipolog City.

NORBERTO C. BAGISPAS

(Affiant)

UMID#CRN-021-1115-3389-2

SUBSCRIBED AND SWORN to before me this ___ day of _________ 201_, at Dipolog City.

Doc. No.__

Page No.__

Book No.__

Series of 2019

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, JOECELYN O. AJERO, of legal age, Filipino, married, a resident of Baybay, Liloy, Zamboanga del Norte after having been
duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of a Postal Identification Card issued by Philippine Postal Corporation and Social
Security System(SSS) ID.
That sometime in April, 2019, while I was checking my bag where I always keep my identification cards, I found out that
my Postal Identification Card and SSS ID were lost, and could not be found;

That despite effort to recover the same but it was naught.

Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for the purpose of
attesting to the loss of the said Philippine Postal Corporation Identification Card and SSS ID.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019, at Dipolog City.

JOECELYN O. AJERO

(Affiant)

PRC ID#0033117

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.

Doc. No.__

Page No.__

Book No.__

Series of 2019

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, LIA JANE R. ENGCO, of legal age, Filipino, single, a resident of Sicayab, Dipolog City, Zamboanga del Norte after having
been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of a Postal Identification Card issued by Philippine Postal Corporation.

That sometime in April, 2019, while I was checking my bag where I always keep my identification cards, I found out that
my Postal Identification Card was lost, and could not be found;

That despite effort to recover the same but it was naught.

Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for the purpose of
attesting to the loss of the said Philippine Postal Corporation Identification Card.
IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019, at Dipolog City.

LIA JANE R. ENGCO

(Affiant)

ID#_________________

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.

Doc. No.__

Page No.__

Book No.__

Series of 2019

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, TERESITA OLVIS, of legal age, Filipino, single, a resident of Turno, Dipolog City, Zamboanga del Norte after having
been duly sworn in accordance with law, hereby depose and state:

That I am a registered owner of a parcel of land known as TCT No. T-1224 located in Dipolog City.

That sometime in November, 2018, while I was checking my file folder of documents where I always keep all documents
with monetary value, I found out that owner’s duplicate copy of the said title was lost, and could not be found;

That despite effort to recover the same but it was naught.

Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for the purpose of
attesting to the loss of the said Transfer Certificate Title No.T-1224.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019, at Dipolog City.

TERESITA OLVIS

(Affiant)

TIN#041-240-192
SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.

Doc. No.__

Page No.__

Book No.__

Series of 2019

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, RAKEL ROSE I. BACAREZA, of legal age, Filipino, a resident of Dipolog City, Zamboanga del Norte after having been
duly sworn in accordance with law, hereby depose and state:

That I am a possessor and holder of a valid Certificate of Registration as a licensed Medical Technologist.

That sometime in November, 2017, while I was checking my documents I found out my Certificate of Registration was
lost, and could not be found;

That despite effort to recover the same but it was naught.

Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for the purpose of
attesting to the loss of the said Certificate of Registration.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019, at Dipolog City.

RAKEL ROSE I. BACAREZA

(Affiant)

ID#_____________

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.

Doc. No.__

Page No.__
Book No.__

Series of 2019

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, DALILA S. QUINLAN, of legal age, Filipino, widow, a resident of 327 Estaka St., Estaka, Dipolog City, Zamboanga del
Norte after having been duly sworn in accordance with law, hereby depose and state:

That I am a possessor and holder of a valid Philippine Passport.

That sometime on March 4, 2019, while I was checking my documents and passport for my travel application abroad at a
bus in the Dipolog City Integrated Terminal I found out my passport was lost, and could not be found;

That despite effort to recover the same but it was naught.

Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for the purpose of
attesting to the loss of the said Philippine Passport.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019, at Dipolog City.

DALILA S. QUINLAN

(Affiant)

OSCA ID#17608-Dipolog City

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.

Doc. No.__

Page No.__

Book No.__

Series of 2019
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, ARMILA B. LIAGUA, of legal age, Filipino, married, a resident of Laoy, Olingan, Dipolog City after having been duly
sworn in accordance with law, hereby depose and state:

That I am an owner, possessor and holder of a wallet color white containing my PRC license, Non-professional LTO
driver’s license, Original Copy of the Certificate of Registration(CR) and Official Receipt(OR) of Yamaha Mio-I 125 color
Magenta, one bracelet, one USB Toshiba brand, other identification cards and One Thousand Five Pesos(P1,500.00).

That sometime on April 21, 2019 at around 9:30 in the evening, while I was checking my wallet while I was at Dipolog
Boulevard, I found out my wallet and all abovementioned were lost, and could not be found;

That despite effort to recover the same but it was naught.

Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for the purpose of
attesting to the loss of the said wallet and all others abovementioned.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019, at Dipolog City.

ARMILA B. LIAGUA

(Affiant)

UMID ID#CRN-006-0050-0219-1

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.

Doc. No.__

Page No.__

Book No.__

Series of 2019
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF RECOVERY

I, JINKY MAE CAGBABANUA CAMARILLO, of legal age, Filipino, single, a resident of P. Zamora Ext. St., Estaka, Dipolog
City after having been duly sworn in accordance with law, hereby depose and state:

That I am a possessor and holder of a Philippine Passport with No.P4852791A which remains valid until October 26,
2022.

That sometime on March 25, 2019, I declared that my passport was lost and executed an affidavit of loss relative thereto
and notarized by Atty Ivo Mandantes per Doc No. 628, Page No. 40, Book No. 22 Series of 2019.;

That on April 15, 2019, my passport was retuned and recovered by the undersigned affiant.

Hence, I considered it as returned and in good condition.

As such, I am executing this Affidavit of Recovery to attest to the truth of the foregoing statements and for the purpose
of attesting to the recovery of the said passport.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019, at Dipolog City.
JINKY MAE C. CAMARILLO

(Affiant)

Phil.Passport#P4852791A

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.

Doc. No.__

Page No.__

Book No.__

Series of 2019

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, IRISH R. ARCESO, of legal age, Filipino, single, a resident of Tuburan, Katipunan,Zamboanga del Norte after having
been duly sworn in accordance with law, hereby depose and state:

That I am a possessor and holder of a valid Philippine Passport.

That sometime on January 14, 2019, while I was checking my documents and passport for my travel application abroad
at a bus in the Dipolog City Integrated Terminal I found out my passport was lost, and could not be found;

That despite effort to recover the same but it was naught.

Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for the purpose of
attesting to the loss of the said Philippine Passport.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019, at Dipolog City.

IRISH REGAÑON ARCESO

(Affiant)

Postal ID#PRN M83170297753P

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.

Doc. No.__

Page No.__

Book No.__

Series of 2019

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, MARK ANTHONY R. LACAYA, of legal age, Filipino, married, a resident of Anastacio, Polanco,Zamboanga del Norte
after having been duly sworn in accordance with law, hereby depose and state:

That I am a possessor and holder of a valid driver’s license with official receipt.

That sometime in the third week of January, 2019, while I was checking for the said official receipt in my wallete because
I was processing my documents, it was lost and could not be found;

That despite effort to recover the same but it was naught.

Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for the purpose of
attesting to the loss of the said official receipt.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019, at Dipolog City.

MARK ANTHONY R. LACAYA

(Affiant)

DL#J01-99-030493

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.

Doc. No.__

Page No.__

Book No.__

Series of 2019

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, JINKY MAE CAGBABANUA CAMARILLO, of legal age, Filipino, single, a resident of P. Zamora Ext. St., Estaka, Dipolog
City after having been duly sworn in accordance with law, hereby depose and state:

That I am a possessor and holder of a Philippine Passport with No.P4852791A which remains valid until October 26,
2022.

That sometime in the third week of March, 2019, while I was checking for the said passport in my folder because I was
processing my documents for travel abroad, it was lost and could not be found;

That despite effort to recover the same but it was naught.

Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for the purpose of
attesting to the loss of the said passport.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019, at Dipolog City.
JINKY MAE C. CAMARILLO

(Affiant)

Phil.Passport#P4852791A

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.

Doc. No.__

Page No.__

Book No.__

Series of 2019

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, TEOPISTO O. BORBON, of legal age, Filipino, married, a resident of San Vicente, Dapitan City after having been duly
sworn in accordance with law, hereby depose and state:

That I am the attorney-in-fact of my spouse Clarita Borbon with regard to her UMID /ATM card of UnionBank of the
Philippines with account number 109570753430.

That sometime on December 5, 2018, while I was checking for the said UMID/ ATM card in my wallet, it was lost and
could not be found;

That despite effort to recover the same but it was naught.

Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for the purpose of
attesting to the loss of the said UMID/Atm card and for the purpose of withdrawal of cash from the said account and
replacement of UMID card.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019, at Dipolog City.

TEOPISTO O. BORBON

(Affiant)

OSCA ID#009955-Dapitan City

Issued on November 6 2017

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.

Doc. No.__

Page No.__

Book No.__

Series of 2019

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, RANDY M. ACOYMO, of legal age, Filipino, single, a resident of Barcelona, Dapitan City after having been duly sworn in
accordance with law, hereby depose and state:

That I am a possessor and holder of an original Official Receipt Number 1309647054 and original Certificate of
Registration Number 6559076-6. That the said Official receipt and Certificate of registration covers a motorcycle
ownership under my name with engine number XRM13E077244.

That sometime on December 5, 2018, while I was checking for the said official receipt and certificate of registration in
my folder, it was lost and could not be found;

That despite effort to recover the same but it was naught.

Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for the purpose of
attesting to the loss of the said passport

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019, at Dipolog City.

RANDY M. ACOYMO

(Affiant)

ID#____________________

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.

Doc. No.__

Page No.__

Book No.__
Series of 2019

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, RAINIER MARK VINCENT E. CAGBABANUA, of legal age, Filipino, a resident of Dapitan City, Zamboanga del Norte,
after having been duly sworn in accordance with law, hereby depose and state:

That I am a possessor and holder of driver’s license with number J01-13-003777, valid until 11-19-2019. That the said
driver’s license has an official receipt after I secured the license.

That sometime on December 5, 2018, while I was checking for the said official receipt after it was asked because I had
met an accident, it was lost and could not be found;

That despite effort to recover the same but it was naught.

Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for the purpose of
attesting to the loss of the said passport

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019, at Dipolog City.

RAINIER MARK VINCENT E. CAGBABANUA

(Affiant)

DL#J01-13-0033777 valid until 11/19/2019

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.

Doc. No.__

Page No.__

Book No.__

Series of 2019

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x
AFFIDAVIT OF LOSS

I, ROE OMAR M. ICAO , of legal age, Filipino, married, a resident of Piñan, Zamboanga del Norte, after having been duly
sworn in accordance with law, hereby depose and state:

That I am the head of the Accounting Section of Dr. Jose Rizal Memorial Hospital.

That the Accounting Section has been repository of disbursement vouchers.

That sometime in February 20, 2019, while the personnel of the Accounting Section was checking the Disbursement
Voucher and its supporting documents for Medical Assistance for Indigent Patients(MAIP) Sub-allotment Account with
DV numbers 2018-02-0006(sub-allot.) amounting to P81,175.10 and DV Number 2018-02-005(sub-allot) amounting to
32,185.00, both could not be found;

That despite effort to recover the same but it was naught.

Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for the purpose of
attesting to the loss of the said documents.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019, at Dipolog City.

ROE OMAR M. ICAO

(Affiant)

PRC#132886

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.

Doc. No.__

Page No.__

Book No.__

Series of 2019

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, GERILYN B. SAGARIO , of legal age, Filipino, single, a resident of Calilic, Sibutad, Zamboanga del Norte, after having
been duly sworn in accordance with law, hereby depose and state:

That I am a possessor and holder of an original copy of duly approved plan of Lot 4668-C(LRC)-Psd-118263 surveyed for
Hipolito Sagario duly approved by Department of Environment and Natural Resources.

That sometime in January 18, 2019, while I was checking for the said approved plan but it was lost and could not be
found;
That despite effort to recover the same but it was naught.

Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for the purpose of
attesting to the loss of the said passport

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019, at Dipolog City.

GERILYN B. SAGARIO

(Affiant)

VIN#7217-0014A-G0867GBS20000-0

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.

Doc. No.__

Page No.__

Book No.__

Series of 2019

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, MA. CONSUELO G. ARNAIZ , of legal age, Filipino, a resident of Isis, Polanco, Zamboanga del Norte, after having been
duly sworn in accordance with law, hereby depose and state:

That I am a member of Social Security System and paid all my amortizations for my loan/obligation therein.

That sometime in November 8, 2018, while I was checking for my receipts of payment I found out that one of the receipt
that I made with SBR/TR No.J0201101,P.R.N.J02011605890101, LMS Payment No.08507317 for Billing month of May
2017 and amount of 199.04 was lost and could not be found;

That despite effort to recover the same but it was naught.

Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for the purpose of
attesting to the loss of the said passport
IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019, at Dipolog City.

MA. CONSUELO ARNAIZ

(Affiant)

ID#__________________

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.

Doc. No.__

Page No.__

Book No.__

Series of 2019

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, MARK RYAN S. ODTUJAN, of legal age, Filipino, single, a resident of Polanco, Zamboanga del Norte, after having been
duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of Person with Disability(PWD) Identification card.

That sometime in January 8, 2019 when I was checking my traveling towards Polanco, Zamboanga del Norte from
Zamboanga City I found out that my wallet containing my PWD ID was lost and could not be found;

That despite effort to recover the same but it was naught.

Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for the purpose of
attesting to the loss of the said passport

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019, at Dipolog City.
MARK RYAN S. ODTUJAN

(Affiant)

ID#__________________

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.

Doc. No.__

Page No.__

Book No.__

Series of 2019

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, MARLON V. SAMULDE, of legal age, Filipino, married, a resident of Olingan, Dipolog City, after having been duly sworn
in accordance with law, hereby depose and state:

That I am a holder and possessor of driver’s license issued by LTO with number J01-17-003356.

That sometime in January 8, 2019 when I was checking my traveling towards Cagayan de Oro I found out that my wallet
containing my driver’s license was lost and could not be found;

That despite effort to recover the same but it was naught.

Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for the purpose of
attesting to the loss of the said passport

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019, at Dipolog City.

MARLON V. SAMULDE

(Affiant)

UMID#CRN-0111-3900761-4

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.
Doc. No.__

Page No.__

Book No.__

Series of 2019

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, MARILOU B. MAYORMITA, of legal age, Filipino, married, a resident of Labrador, Polanco, Zamboanga del Norte, after
having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of passbook at Katipunan Bank with account number 001-20-1172513.

That sometime in December 24, 2018 when I was checking my passbook at my file folder I found out that my passbook
was lost and could not be found;

That despite effort to recover the same but it was naught.

Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for the purpose of
attesting to the loss of the said passport

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019, at Dipolog City.

MARILOU B. MAYORMITA

(Affiant)

PRC #0540492

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.

Doc. No.__

Page No.__

Book No.__

Series of 2019
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, EDNA D. BONAFE, of legal age, Filipino, widow, a resident of Minaog, Dipolog City, after having been duly sworn in
accordance with law, hereby depose and state:

That my son MICHAEL KIRK BONAFE is a holder and possessor of Diploma as graduate of Bachelor of Science in
Accountancy at Saint Vincent’s College-Dipolog City in year 2010.

That sometime in December 24, 2018 when I was checking the Diploma of my son at my file folder I found out that the
diploma was lost and could not be found;

That despite effort to recover the same but it was naught.

Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for the purpose of
attesting to the loss of the said passport

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019, at Dipolog City.

EDNA D. BONAFE

(Affiant)

SSS #10-0286168-6

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.

Doc. No.__

Page No.__

Book No.__

Series of 2019

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x
AFFIDAVIT OF LOSS

I, HANNAH LOU D. GUMAPON, of legal age, Filipino, single, a resident of Poblacion South, Polanco, Zamboanga del
Norte, after having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of Diploma as graduate of Bachelor of Science in Social Work at Mindanao State
University- Main Campus(Marawi City).

That sometime in December 24, 2018 when I was checking my Diploma at my file folder I found out that my diploma was
lost and could not be found;

That despite effort to recover the same but it was naught.

Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for the purpose of
attesting to the loss of the said passport

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019, at Dipolog City.

HANNAH LOU D. GUMAPON

(Affiant)

PRC #0018667

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.

Doc. No.__

Page No.__

Book No.__

Series of 2019

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS
I, LETICIA N. RONQUILLO, of legal age, Filipino, married, a resident of Anastacio, Polanco, Zamboanga del Norte, after
having been duly sworn in accordance with law, hereby depose and state:

That I am a holder and possessor of Office of the Senior Citizen’s Affair(OSCA) identification card.

That sometime in December 24, 2018 when I was checking my OSCA ID I found out that my ID was lost and could not be
found;

That despite effort to recover the same but it was naught.

Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for the purpose of
attesting to the loss of the said passport

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019, at Dipolog City.

LETICIA N. RONQUILLO

(Affiant)

ID#____________________

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.

Doc. No.__

Page No.__

Book No.__

Series of 2019

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, GILBERT C. MOJADO, of legal age, Filipino, married, a resident of Sianib, Polanco, Zamboanga del Norte, after having
been duly sworn in accordance with law, hereby depose and state:

That I am an owner and possessor of Driver’s License issued by LTO.

That sometime on December 25, 2018 at around 11:00pm, when I was passing the river I found out that my wallet that
contained my driver’s license was lost and could not be found;

That despite effort to recover the same but it was naught.

Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for the purpose of
attesting to the loss of the said passport

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2019, at Dipolog City.

GILBERT C. MOJADO

(Affiant)

CTC#CCI201721720649 issued on 1/24/19

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2019, at Dipolog City.

Doc. No.__

Page No.__

Book No.__

Series of 2019

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, GEOVANNE D. AGAD, of legal age, Filipino, single, a resident of Guinles, Polanco, Zamboanga del Norte, after having
been duly sworn in accordance with law, hereby depose and state:

That I am an owner and possessor of Driver’s License issued by LTO.

That sometime on December 31, 2018 at around 11:00pm, when I was walking, I found out that my wallet that
contained my driver’s license was lost and could not be found;

That despite effort to recover the same but it was naught.

Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for the purpose of
attesting to the loss of the said passport

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2018, at Dipolog City.

GEOVANNE D. AGAD

(Affiant)
Philhealth ID#19-025424463-9

With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2018, at Dipolog City.

Doc. No.__

Page No.__

Book No.__

Series of 2018

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, VINCENT Z. CARMEN, of legal age, Filipino, married, a resident of Sindangan, Zamboanga del Norte, after having been
duly sworn in accordance with law, hereby depose and state:

That I am an owner and possessor of Receipt #60809SG006624 of Cebuana Lhuillier for a loaned item of ring with loan
date:9/03/18; expiry date:1/02/19.

That sometime on November 21, 2018 at around 11:35am, when I was checking for the files, I found out that Original
Receipt was lost and could not be found;

That despite effort to recover the same but it was naught.

Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for the purpose of
attesting to the loss of the said passport

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2018, at Dipolog City.

VINCENT Z. CARMEN

(Affiant)

ID#__________________________

With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2018, at Dipolog City.
Doc. No.__

Page No.__

Book No.__

Series of 2018

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, AMANCIO C. JARMIN, of legal age, Filipino, married, a resident of Isis, Polanco, Zamboanga del NOrte, after having
been duly sworn in accordance with law, hereby depose and state:

That I am a possessor of the updated Original Official Receipt and Certificate of Registration of the vehicle purchase by
my son Randy Jarmin; which has the following details:

CR NO.:8254871-2 MV File No: 0724-00000012228

Plate No.:JVL130 Engine No. F6A-6613820

Chassis No.:DC51T-434963;

That sometime on November 21, 2018 at around 11:35am, when I was checking for the files, I found out that Original
OR/CR of the abovenamed vehicle was lost and could not be located;

That despite effort to recover the same but it was naught.

Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for the purpose of
attesting to the loss of the said passport

IN WITNESS WHEREOF, I have hereunto affixed my signature this 22nd day of November 2018, at Dipolog City.

AMANCIO C. JARMIN

(Affiant)

OSCA ID#18-01350-Polanco, ZN_

With photo

SUBSCRIBED AND SWORN to before me this 22nd day of November 2018, at Dipolog City.

Doc. No.__

Page No.__
Book No.__

Series of 2018

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, AMANCIO C. JARMIN, of legal age, Filipino, married, a resident of Isis, Polanco, Zamboanga del NOrte, after having
been duly sworn in accordance with law, hereby depose and state:

That I am a possessor of the updated Original Official Receipt and Certificate of Registration of the vehicle purchase by
my son Randy Jarmin; which has the following details:

CR NO.:8254871-2 MV File No: 0724-00000012228

Plate No.:JVL130 Engine No. F6A-6613820

Chassis No.:DC51T-434963;

That sometime on November 21, 2018 at around 11:35am, when I was checking for the files, I found out that Original
OR/CR of the abovenamed vehicle was lost and could not be located;

That despite effort to recover the same but it was naught.

Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for the purpose of
attesting to the loss of the said passport

IN WITNESS WHEREOF, I have hereunto affixed my signature this 22nd day of November 2018, at Dipolog City.

AMANCIO C. JARMIN

(Affiant)

OSCA ID#18-01350-Polanco, ZN_

With photo

SUBSCRIBED AND SWORN to before me this 22nd day of November 2018, at Dipolog City.

Doc. No.__

Page No.__

Book No.__

Series of 2018
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF CHANGE OF CLASS

I, JUN ROWEL C. ARCADIO, of legal age, Filipino, single, a resident of Dapitan City, after having been duly sworn in
accordance with law, hereby depose and state:

That I am the new registered owner of a motor vehicle described as follows:

Make; Honda Plate#:JX8064

Engine#:XRM13E-015839 Chassis#:XRM13015839

Color:Red Denomination:Tricycle

MV File:0908-00003294738 CR#4630243-2

That I am changing the class of the tricycle with franchise as public convenience/transportation/for hire to private
vehicle with cab;

As such, I am executing this affidavit to attest to the truth of the foregoing statements and for the purpose of registering
the vehicle.

IN WITNESS WHEREOF, I have hereunto affixed my signature this 15th day of November 2018, at Dipolog City.

JUN ROWEL C. ARCADIO

(Affiant)

DL#J01-01-036966

Until 10/27/19

With photo

SUBSCRIBED AND SWORN to before me this 15th day of November 2018, at Dipolog City.

Doc. No.__

Page No.__

Book No.__

Series of 2018

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS
I, CATHERINE KELLY, of legal age, Filipino, single, a resident of Dipolog City, after having been duly sworn in accordance
with law, hereby depose and state:

That I am an authorized agent of Millenium Distribution System, Inc. and as an agent I am a custodian of sales invoices
and receipts;

That sometime on October 19, 2018 at around 11:35am, when I was checking for my files of Sale invoices, I found out
that Sale Invoice No.006117 was lost and could not be located;

That despite effort to recover the same but it was naught.

Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for the purpose of
attesting to the loss of the said passport

IN WITNESS WHEREOF, I have hereunto affixed my signature this 15th day of November 2018, at Dipolog City.

CATHERINE KELLY

(Affiant)

ID#________________

With photo

SUBSCRIBED AND SWORN to before me this 15th day of November 2018, at Dipolog City.

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Page No.__

Book No.__

Series of 2018

Republic of the Philippines. . . . . . )

City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF LOSS

I, VILMA A. REMPERAS, of legal age, Filipino, married, a resident of Singaran, La Libertad, Zamboanga del Norte, after
having been duly sworn in accordance with law, hereby depose and state:

That I am the owner/ holder of jewelries, cash, legal documents and clothings;

That sometime on October 19, 2018 at around 1:35am, when a room of my house was burned, the above-mentioned
personal belongings were also burned and could not be located;

That despite effort to recover the same but it was naught.

Hence, I considered it as totally lost.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and for the purpose of
attesting to the loss of the said passport

IN WITNESS WHEREOF, I have hereunto affixed my signature this 5th day of November 2018, at Dipolog City.

VILMA A. REMPERAS

(Affiant)

DL ID# J01-09-002475

Valid until 3/9/23

With photo

SUBSCRIBED AND SWORN to before me this 5th day of November 2018, at Dipolog City.

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Page No.__

Book No.__

Series of 2018

Republic of the Philippines)

City of Dipolog ) S.S

X-------------------/

AFFIDAVIT OF USE GARAGE

I, FE VALENCIA, of legal age, Filipino, married a resident of Lingasad, Polanco, Zambaonga del Norte, after
being duly sworn to an oath in accordance with law, depose and state the following:

That I am the owner of a motor vehicle, more particularly described as follows:

Make - - - Suzuki Chassis # LTO-067476-RO7-C

Plate # - - JVD249 Cert of Registration # 41738185

 Type of Body – Jitney Motor No. - - - 021-7705

That because of the limited space, I have no garage to park the vehicle;

However, I am renting the space owned by Forferia Estaniel, so that my aforesaid vehicle can parked.

That I am executing this affidavit to attest to the truthfulness of the foregoing statement above stated.

IN WITNESS WHEREOF, I, have hereunto affixed my signature this 14th day of June 2018, at Dipolog City.

FE VALENCIA

(Affiant)

ID # ___________

SUBSCRIBED AND SWORN to before me this 14th day of June 2018, at Dipolog City.
ATTY. EULO. L. LAGUDAS, JR.

NOTARY PUBLIC

UNTIL DECEMBER 31, 2010

IBP No. 775120 1-8-10

PTR No. 2407802 1-15-10

ROLL OF ATTORNEYS NO. 56396

DOC. NO. 821

PAGE NO. 80

BOOK NO. 2

SERIES OF 2010
Republic of the Philippines. . . . . . )
City of Dipolog . . . . . . . . . . . . . . . )S.S
x---------------------- x

AFFIDAVIT OF UNDERTAKING

I, SULAYMAN MARTINEZ ALAMADA, of legal age, Filipino, married, with address at Guimotan,
Baliguian, Zamboanga del Norte, after having been duly sworn in accordance with law, hereby
depose and state:
 1. That I am the Barangay Captain of Barangay Guimotan, Baliguian, Zamboanga del Norte, which
will conduct the Barangay Guimotan Founding Anniversary this coming April 20, 2024; and in
connection with the latter, I received an amount of TEN THOUSAND PESOS (10,000.00) as
Financial Assistant for the Basketball Tournament for the Araw ng Guimotan from the
PROVINCIAL GOVERNMENT OF ZAMBOANGA DEL NORTE (PGO-ZN);

2. That I shall undertake to comply and submit the required documents such as OFFICIAL
RECEIPT(OR)

As such, I am executing this Affidavit to attest to the truth of the forem,going statements in order to
justify my late report to the Bureau of Immigration and/or renew my ACR and/or Visa.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of __________ 2024, at
Dipolog City.

MICHAEL DOUGLAS DEGRAZIA

(Affiant)
Driver’s License#J01-22-304967
Valid Until 01/01/2027
With photo

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2024, at Dipolog City showing
his/her document of identity as indicated above.
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Series of 2024