Republic of the Philippines)

Province of Bulacan ) S.S.

City of Malolos )

AFFIDAVIT OF LOSS

I, ___________________________, of legal age, married

and a resident of No. 11 Bagong Ilog, Brgy. Iba,
Municipality of Hagonoy, Bulacan. After having been duly
sworn in accordance with law, hereby depose and say:

1. That, I have a check issued by LANDBANK OF THE

PHILIPPINES dated sometime in OCTOBER 2017;

2. That said check was issued to me by OFFICE OF THE

CONGRESSMAN _____________________ as BURIAL
ASSISTANCE for the death of my uncle
_______________ ;

3. That value of the said check was TWO THOUSAND

PESSOS (P2,000.00);

4. That on January 6, 2018, I went to the Police

Station of Malolos PNP to follow up matters with
personally I cannot fully divest;

5. That when I am about to finish my transaction, I

noticed that the said check was no longer in my
wallet;

6. That, as much as I try to exert any effort to

notify and report such loss, the fact that it
happen on a Saturday leaves me no choice but to
wait until Monday in order to report the said
incident;

7. That, I further execute this affidavit to attest

the truthfulness and veracity of the foregoing
facts and for whatever legal intent and purposes it
is deemed proper.

IN WITNESS WHEREOF, I hereunto affix my signature

below this ___ day of January 2018, at City of Malolos,
Bulacan.

_______________________
Affiant

SUBSCRIBED AND SWORN to before me this __day of

January 2018 at City of San Jose Del Monte, Bulacan;
Affiant exhibiting to me her Social Security I.D. No. 33-
8042263-5 issued on sometime in May, 2012, issued at the
City of Malolos, Bulacan.

NOTARY PUBLIC
Doc. No. ____;
Page No. ____;
Book No. ____;
SERIES OF 2018