Republic of the Philippines)

City of Dipolog )S.S.

AFFIDAVIT OF LOSS

I, GENOVEVA E. GERIBISE, Filipino, of legal age, widow and a resident

of New Dapitan, Rizal Zamboanga del Norte after having been duly sworn to in
accordance with law, hereby depose and say THAT:

1. I am the plan holder of the Life Plan plus Agreement of St. Peter Life
Plan and I have paid in full said life plan and as such, I was issued a
Certificate of Full Payment;

2. Unfortunately however, I misplaced the said Certificate of Full Payment

and I could not determine where, when and how exactly it got lost;

3. I exerted earnest efforts to look for the Certificate of Full Payment but
unfortunately, I could no longer find it; and

4. I execute this affidavit to attest to the foregoing facts for whatever legal
purpose it may serve.

IN WITNESS WHEREOF, I hereunto set my hand this ________, in the City

of Dipolog, Philippines.

GENOVEVA E. GERIBISE
Senior Citizen’s ID No. RND-049
Affiant

SUBSCRIBED, SIGNED, AND SWORN TO in my personal presence, this

____________ at Dipolog City, Philippines, affiant identified through his
competent proof of identity, the particulars of which are above-mentioned,
which bear his photograph and signature, and who avowed under penalty of
law to the whole truth of the contents of the instrument or document, which
he executed freely and voluntarily.

Doc No._____
Page No.____
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Series of 2020