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REPUBLIC OF THE PHILIPPINES)

PROVINCE OF OCCIDENTAL MINDORO)S.S


MUNICIPALITY OF SABLAYAN)

AFFIDAVIT OF DEATH AND HEIRSHIP


I, LIZA S. DELA CRUZ Filipino, of legal age, widow and presently
residing at 3333 M. Ocampo Street, Pio del Pilar, Makati City, after having been
duly sworn to in accordance with law, do hereby depose and say:

1. That I am the widow of BENITO D. DELA CRUZ who died on July 30,
2013 in Quezon City because of head injuries sustained in a vehicular
accident as per autopsy result conducted by Dr. Lito R. Santos;

2. That per investigation of the Quezon City Police Station, my husband


was driving along the northbound lane of EDSA in front of Camp
Aguinaldo in Quezon City when he was hit/bumped by a truck coming
from the opposite direction; copy of the Traffic Investigation Report is
hereto attached as Annex "A";

3. That at the time of the incident, my husband was a duly licensed


driver carrying Driver's License No. 123456 and was riding on a Toyota
Innova, gray in color and with Plate No. XYZ-123 owned by me with
Certificate of Registration No. 55667788;

4. We are the surviving parents of _____________________ who died on


single and without any legitimate children on_______________in
____________________________;

5. As evidence of our legal relation to the deceased, photocopies of our


birth certificates are herein attached; and

6. As evidence of the single status of _______________________,


photocopies of his Certificate of No Marriage is herein attached;

7. That I am executing this affidavit in support of my application for


insurance claim with _____________, to attest to the truth of the foregoing,
and for whatever legal purposes it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this 6th day of


October 2013 at Makati City, Philippines.

LIZA S. DELA CRUZ


Affiant

SUBSCRIBED AND SWORN to before me this 6th day of October 2013


in the City of Makati, Philippines, affiant exhibiting to me her competent
evidence of identity by way of Philippine Passport No. 12344 issued at Manila,
Philippines on September 5, 2012.

Doc No. : _____


Page No.: ______
Book No.: ______
Series of 2013
REPUBLIC OF THE PHILIPPINES)
PROVINCE OF OCCIDENTAL MINDORO)S.S
MUNICIPALITY OF SABLAYAN)

AFFIDAVIT OF LOSS (FIREARM)

I, FILOMENA O. CAMBA, Filipino, of legal age, widowed and a resident


of Barangay Buenavista, Sablayan, Occidental Mindoro, after being duly sworn
in accordance with law, depose and state:

1. That I am the true and licensed owner of a one (1) unit 380 LLAMA
Pistol firearm with Serial No. 07-04-16694-97.

2. That on September 26, 2017, a fire broke on our kitchen due to a


leaked LPG hose burning almost entirely my house down.

3. That after the Bureau of Fire Sablayan, declared a fire out, I searched
for the said pistol, but despite diligent efforts I can no longer find the same;

4. That a BFP Certification of the fire incident is herein attached and


made an integral part of this document;

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


the foregoing.

IN WITNESS WHEREOF, I have hereunto set my hand this _____________ at


_____________, Philippines.

FILOMENA O. CAMBA
AFFIANT

SUBSCRIBED AND SWORN to before me this ____th day of ____________ 2018


in the Municipality of Sablayan, Province of Occidental Mindoro, affiant
exhibiting to me her competent evidence of identity by way of Philippine
I.D/CTC with no.__________________ issued at _________________________
on _______________________.

Doc No. : _____


Page No.: ______
Book No.: ______
Series of 2018