7/24/2019 SSS AOL
1/1
REPUBLIC OF THE PHILIPPINES }CITY OF DIGOS, DAVAO DEL SUR}
AFFIDAVIT OF LOSS
I, ROSALYN A. DOMIDER, Filipino, of legal age,ingle an! a
"ei!en# of Blo$% &' Lo# '( Don Lo"en)oHo*e T"e !e +ao Digo Ci#,
Da-ao !el S.", P/ilippine,af#e" /a-ing 0een !.l 1o"n #o in
a$$o"!an$e 1i#/ la1, !o/e"e0 !epoe an! a #/a#2
&3 I a* #/e a*e an! i!en#i$al pe"on 1/o 1a i.e! aN.*0e" 0
So$ial Se$."i# S#e* 4SSS56
73 T/e ai! i!en#i8$a#ion $a"! 1a no1/e"e #o 0e fo.n!a*ong * 8le3
I $an no longe" "e$all #/e pe$i8$$i"$.*#an$e .""o.n!ing i# lo, 0.#
!iligen# e9o"# #olo$a#e #/e a*e in pla$e 1/e"e i# /o.l! no"*all
0elo$a#e!, p"o-e! f.#ile an! .niel!ing6
'3 I a*, #/e"efo"e e:e$.#ing #/i a9i!a-i# #o app"ie #/eSo$ial
Se$."i# S#e* 4SSS5 of #/e fa$# of #/e lo of *i!en#i8$a#ion
$a"!3
FURTHER AFFIANT SAYETH NAUGHT3
IN ;ITNESS ;HEREOF, I /a-e /e"e.n#o e# * /an!7o#/ !a of , in
Digo Ci#, Da-ao !el S.", P/ilippine,a9ian# /a-ing e:/i0i#e! #o *e
/e" P/il Plan ID No3&&=&>'>'(, -ali! .n#il
De$e*0e" '&, 7=&> a# Digo Ci#3
NOTARY PUBLIC
