Affidavit - Loss (Due to Fire)

Republic of the Philippines ) Municiplaity of Camiling ) Province of Tarlac ) JOINT AFFIDAVIT OF LOSS ____________ We, MILDRED G. AGUSTIN and Spouses MELCHOR M. AGUSTIN and REMEDIOS G. AGUSTIN, all of legal age, Filipinos, a residents of Quezon Avenue, Poblacion I, Camiling, Tarlac after having been jointly sworn to in accordance with law, hereby depose and allege, that: 1. That on March 22, 2008 our residence located along Quezon Avenue, Camiling, Tarlac was burned and destroyed by fire; 2. As a result of the fire, most of our belongings and personal properties including the following important items were destroyed or lost, to wit: MILDRED G. AGUSTIN

1. Passport; 2. Transcript of School Records (College of the Holy Spirit and Philippine Normal University), Diploma (College of the Holy Spirit and Camiling Central Elementary School); 3. PRC – Teachers License; 4. Student ID’s (PNU and UP); 5. Employees ID and Certificate of Employments (I Can Language Center, W. English. Inc., Camiling School of Home Industries); 6. Certificate of Confirmation, Certificate – Seminars/short courses (PNU); 7. School Forms, Class records (Camiling School of Home Industries); 8. ATM’s, Credit and other transaction cards; 9. and other important documents of such nature.

REMEDIOS G. AGUSTIN

1. 2. 3. 4.

Passport; Phil. Savings Bank Passbook Senior Citizen Card ATM’s, Credit and other transaction cards

MELCHOR M. AGUSTIN

1. PVAO ATM Card; 2. Land Titles 3. Records and documents pertaining to real properties

3. The fire that destroyed our residence was recorded by the concerned government agencies. A certification concerning the fire is hereto attached as Annex “A”; 4. We are executing this affidavit to inform those concerned about the loss and destruction of the above-mentioned items or documents; 5. We attest to the truth of the foregoing facts. IN WITNESS WHEREOF, We hereunto affix our signatures this 24th day of March 2008 at Camiling, Tarlac.

MILDRED G. AGUSTIN Affiant CTC No. _________ Issued at ________ Issued on ________

REMEDIOS G. AGUSTYIN Affiant CTC No. _____________ Issued at ____________ Issued on ____________

MELCHOR M. AGUSTIN Affiant CTC No. __________ Issued at ___________ Issued on ___________

SUBSCRIBED AND SWORN to before me on the date and place indicated above. Affiants exhibited before me their Community Tax Certificate Numbers as indicated below their signed names.