REPUBLIC OF THE PHILIPPINES..

)
PROVINCE OF SAMAR…………….) SS
CITY OF CATBALOGAN……………)

AFFIDAVIT OF LOSS

I, DOMINGO MABULAY ABAYARE, of legal age, married, Filipino and

with residence at Brgy. Rawis, Hinabangan, Samar, after having been duly sworn
to in accordance with law do hereby depose and state: THAT-

1. I am a member of NATCCO-OCCCI Cooperative, Catbalogan

Branch, Catbalogan City; as such, I was issued a savings passbook
in my favor;

2. On 20 May 2017, however, as I was collating my pertinent papers

at home, I discovered that said OCCCI passbook was missing or I
might misplaced it somewhere but couldn’t locate it despite repeated
searched;

3. This declaration is made in good faith and not intended to defraud

the government, the NATCCO-OCCCI and third persons, and I
hereby hold myself liable for any responsibilities arising from such
loss;

4. I am executing this statement to attest the truth of all the foregoing

and to request the NATCCO-OCCCI for replacement of a
passbook in lieu of the one lost and for other legal purposes. .

IN WITNESS WHEREOF, I hereunto affix my signature this 25th day of July

2017 at Catbalogan City.

DOMINGO MABULAY ABAYARE

Affiant

SUBSCRIBED AND SWORN to before me this 25th day of July 2017 at

Catbalogan City, affiant exhibiting to me his Senior Citizen ID No. 011-052 issued on
Feb. 7, 2011.
REPUBLIC OF THE PHILIPPINES…..)
PROVINCE OF SAMAR…………….) SS
CITY OF CATBALOGAN……………)

AFFIDAVIT OF LOSS

I, CONCESA DACLES-QUEBEC, of legal age, widow, Filipino and with

residence at Brgy. Casandig, Paranas, Samar, after having been duly sworn to in
accordance with law do hereby depose and state: THAT-

5. I am the wife of the late Antonio O. Quebec who died on June 28,
2017 at the Samar Provincial Hospital, Catbalogan City;

6. That my said late husband during his lifetime was a coconut farmer;
as such, he was a member-beneficiary of COCOLIFE with
Certificate of Group Life Insurance No. PP: 00226 issued on June
12, 2002;

7. Lately, however, as I was collating said deceased’ pertinent papers

at home, particularly, his COCOLIFE documents, I discovered that
the application form supposedly attached to the Certificate of Group
Life Insurance, was missing and repeated search for it proved futile,
such that I now considered it lost for all intents and purposes;

8. This declaration is made in good faith and not intended to defraud

the government, the COCOLIFE and third persons, and I hereby
hold myself liable for any responsibilities arising from such loss;

9. I am executing this statement to attest the truth of all the foregoing

and for claims and other legal purposes. .

IN WITNESS WHEREOF, I hereunto affix my signature this 18th day of July

2017 at Catbalogan City.

CONCESA DACLES- QUEBEC

Affiant

SUBSCRIBED AND SWORN to before me this 18th day of July 2017 at

Catbalogan City, affiant exhibiting to me her Voter’s ID No. 6022-0030B-
C0462CD020000.
REPUBLIC OF THE PHILIPPINES…..)
PROVINCE OF SAMAR…………….) SS
CITY OF CATBALOGAN……………)

AFFIDAVIT OF LOSS

I, MAUREEN LOTOC ASILO, of legal age, single, Filipino and with

residence at Brgy. 3, Pier 2, Catbalogan City, after having been duly sworn to in
accordance with law do hereby depose and state: THAT-

10. I am a holder of a National Certificate II (Certificate No.

15086002005430) in Food and Beverages Services issued by
Technological Education and Skills Development Authority
(TESDA) on November 6, 2015 and valid until November 6, 2020;

11. On 21 September 2016, however, while I was in Boracay,

as I was collating my pertinent papers at home, I discovered that
said OCCCI passbook was missing or I might misplaced it
somewhere but couldn’t locate it despite repeated searched;

12. This declaration is made in good faith and not intended to defraud
the government, the NATCCO-OCCCI and third persons, and I
hereby hold myself liable for any responsibilities arising from such
loss;

13. I am executing this statement to attest the truth of all the foregoing
and to request the NATCCO-OCCCI for replacement of a
passbook in lieu of the one lost and for other legal purposes. .

IN WITNESS WHEREOF, I hereunto affix my signature this 14th day of July

2017 at Catbalogan City.

MAUREEN LOTOC ASILO

Affiant

SUBSCRIBED AND SWORN to before me this 14th day of July 2017 at

Catbalogan City, affiant exhibiting to me her ID No.___________________.