Affidavit of Loss COP

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Republic of the Philippines )

City of Butuan )S.S.

AFFIDAVIT OF LOSS

I, CHEENIE SHEEN H. BILLONES, of legal age, Filipino and a


resident Blk 6, Lot 9, Phase 3-Emenville Sudb., Butuan City after having
been duly sworn according to law depose and state:

1. That I am a holder of Certificate of Proficiency (COP) issued under


the Provisions of the International Convention on Standards of
Training, Certification and Watchkeeping for Seafarers by Maritime
Industry Authority (MARINA) Butuan City;

2. That I lost the said Certificate sometime last month of August, 2017
and that I exerted all efforts to locate the same but could not
remember exactly where I placed it and considered it lost for all legal
purposes;

3. That the said Certificate was not confiscated by any officer of the law
by reason of any violation of any law, ordinance or presidential
decree, rules or regulation of the said Office;

4. That I am executing this Affidavit to inform the Maritime Industry


Authority (MARINA) Butuan City that the said Certificate was lost
and never recovered;

5. That I attest to the truth of the foregoing facts.

FURTHER AFFIANT SAYETH NONE.

IN WITNESS WHEREOF, I have hereunto set my hand this September


07, 2017 in Butuan City, Philippines.

CHEENIE SHEEN H. BILLONES


Affiant

SUBSCRIBED and SWORN TO before me this September 07, 2017 in


Butuan City, affiant exhibiting to me her Passport I.D: EC5548341 as proof
of her identity.

Doc. No._______
Page No._______
Book No._______
Series of 2017

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