REPUBLIC OF THE PHILIPPINES

PROVINCE OF SORSOGON
CITY OF SORSOGON
AFFIDAVIT OF LOSS
I, DELIA E. SUPILANA, of legal age, Filipino, widow, and a resident of
Brgy. Calaw, Prieto Diaz, Sorsogon, after having been duly sworn in accordance
with law, hereby depose and say:

That I am a DEPED Teacher and a registered member of the

Mutual Aid System of the Manila Teachers Mutual Aid System,
Inc, 91 Gen. Luna St., Malabon, Metro Manila;

That a Mutual Retirement Benefit System (MRBS) Policy

contract was issued to me;

That unfortunately said MRBS Policy contract was misplaced

when the Province of Sorsogon was devastated by a typhoon
last July, 2014 and could no longer be located at our residence;

That due efforts has been made in order to retrieve said MRBS
Policy contract, but to no avail, thus, I am considering it lost
forever;

That I am executing this affidavit to attest to the foregoing facts

and for purposes of my claim application for benefit under the
Mutual Retirement Benefit System.

IN WITNESS WHEREOF, I have hereunto affixed my signature this 8 th

day of June 2015 at Sorsogon City.

DELIA E. SUPILANA
SUBSCRIBED AND SWORN to before me this 8 th day of June 2015,
affiant exhibited his Deped Employee ID No. 5020660.