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REPUBLIC OF THE PHILIPPINES)

CITY OF NAGA CITY ) S.S.

x-------------------------------------x

 

AFFIDAVIT OF LOSS

I, MARK ANTHONY R. TALLO, of legal age, Filipio, !igle a" a #e!i"e$ of Bolo

No#$e, Sipo%o$ Ca&a#ie! S'#, af$e# (aig *ee "'l+ !o# $o i a%%o#"a%e i$( la, "epo!e

a" !$a$e

. T(a$ I a& a (ol"e# of Fo#& /0 "'l+ i!!'e" i &+ fao# *+ Bolo No#$e, Hig(!%(ool o 1a#%( /2,

3224 i $(e !ai" !%(ool5

3. T(a$ I '!e" $o p'$ !ai" #epo#$ %a#" i &+ *ag5

/. T(a$ !o&e$i&e o Ap#il 32, 326, (e I a##ie" (o&e f#o& loo7ig fo# a 8o*, I "i!%oe#e" $(a$

!ai" #epo#$ %a#" a! o loge# i &+ *ag5

6. T(a$ "ilige$ effo#$ $o lo%a$e $(e !a&e p#oe" f'$ile5

9. T(a$ i ie $(e#eof, I o "e!i#e a" (e#e*+ #e:'e!$ $o a e #epo#$ %a#" i lie' of $(e lo!$

oe5

;. T(a$ I *i" &+!elf $o !ae $(e !ai" !%(ool of $(e (a#&le!! f#o& a+ lo!! o# "a&age $(a$ i$ &a+

i%'# i %oe%$io i$( $(e i!!'a%e of a e #epo#$ %a#" i lie' of $(e lo!$ oe5

4. T(a$ I a& exe%'$ig $(i! affi"ai$ $o a$$e!$ $o $(e fo#egoig fa%$! a" fo# a+ legal p'#po!e i$

&a+ !e#e.

  IN <ITNESS <HEREOF, I (ae (e#e'$o !e$ &+ (a" $(i! /2$( "a+ of 1a#%(. 32; a$

Bolo No#$e, Sipo%o$ Ca&a#ie! S'#. 

Name Over Signature of Affiant

SUBSCRIBE= AN= S<ORN $o *efo#e &e, $(i! >>>> "a+ of >>>>>>>>>>>>>>, 32>>> i

 >>>>>>>>>>>>>>>>>>> Ci$+, i$( affia$ ex(i*i$ig (i! CTC No. >>>>>>>>>>>>>>> ,I!!'e" o >>>>>>>>>>>>>>>>>>>>>> a$ >>>>>>>>>>>>>>>>>>>>>>>>>.

 

=o%. No. >>>>>>>>5Page No. >>>>>>>>5

Boo7 No. >>>>>>>>5

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