I, Full Name of Plan Holder of legal age, Single / Married Filipino Citizen, and with residence at Lot/Blk/Phse No. Subdivision or House No. , Barangay , Municipality/City , Province having been duly sworn to in accordance with the law, depose and say:
That I am a bonafide Planholder of ST. PETER LIFE PLAN, INC. under Life Plan Contract No. LPA Number (please refer above) .
That the original documents issued in my favor by the ST. PETER LIFE PLAN, INC. pertaining to the said Life Plan Contract Number's Please Select Life Plan Agreement Plan Holder Identification Card Both the Life Plan Agreement and Plan Holder Identification Card has/have been misplaced and could not be found;
That I exerted all efforts to look for the mentioned documents but to no avail;
That I executed this affidavit to attest the truth of the foregoing facts and circumstances and to establish such loss for the purpose of securing a new copy that thereof from ST. PETER LIFE PLAN, INC.
IN WITNESS HEREOF, I hereto affix my signature this Date day of Month , 20 Year .