REPUBLIC OF THE PHILIPPINES)

TAGUM CITY . . . . . . . . . . . . .) S.S.

AFFIDAVIT OF LOSS
I, RODOLFO C. RAPISTA, of legal age, Filipino, married and a
resident of 1376 Mirasol St., Suaybaguio District, Magugpo North, Tagum
City, Davao del Norte, Philippines, after having been sworn to in accordance
with law, hereby depose and state:
That on June 29, 2012, I paid the amount of FIVE THOUSAND
(P5,000.00) PESOS under BIR FORM No. 0605 with LandBank, Tagum City
Branch;
That I was issued with an official receipt by LandBank, Tagum City
Branch as evidence for the said payment;
That recently, I noticed that the said official receipt is no longer in my
files where I kept it;
That I looked in every possible place that I could have placed it but
despite diligent efforts, the same could no longer be found, thus I consider it
lost beyond recovery for all intents and purposes;
That I am executing this affidavit to attest to the truthfulness and the
veracity of the foregoing facts and in connection with the requirements of
the District Revenue Officer, BIR, Tagum City for the issuance of Certification
attesting to BIR Commissioner, Quezon City, that I have already paid the
said amount.
IN WITNESS WHEREOF, I have hereunto set my signature this
__________________ at Tagum City, Philippines.
RODOLFO C. RAPISTA
Affiant
TIN: 284-814-279
SUBSCRIBED AND SWORN to before me this ________________ at
Tagum City, Philippines.

Doc. No. ____;

Page No. ____;
Book No. ____;
Series of 2013.