AFFIDAVIT OF LOSS

I, SSg Jaime S Sta Cruz 656028 PAF , of legal age, Filipino, single/married, and resident
Apartment Nr 6 AFPMC Compound V Luna Ave Quezon City after being duly sworn according

of

to law,

hereby depose and state that:

1.

I am a TIAC inspector and thus, held the WO Nr 406 th-AFPMC-R&U-15-05-046 for V.S

CERDON IRON WORKS & CONSTRUCTIONS issued by the 406 th Contracting Office, AFPPS, AFPMC on 06
May 2015.

2.

Sometime in November 2015, said WO Nr 406th-AFPMC-R&U-15-05-046 was misplaced and got lost.

3.

Despite diligent efforts exerted, I could no longer locate, find or recover the said WO Nr 406 th-AFPMC-R&U-1505-046, and to the best of my knowledge, the same is truly lost.

4.

The said WO Nr 406th-AFPMC-R&U-15-05-046 has not been confiscated by any officer of the

law or the issuing office or agency due to the violation of any law, statute, order, rule or regulation.

5.

I am executing this Affidavit to attest to the truth of the foregoing statements and to request the issuance of a
new WO Nr 406th-AFPMC-R&U-15-05-046 in lieu of the one which was lost.

AFFIANT FURTHER SAYETH NAUGHT.

IN WITNESS WHEREOF, I have hereunto set my

hand this

at

SSg Jaime S Sta Cruz 656028 PAF

Affiant
SUBSCRIBED AND SWORN to before me this
his/her Competent Evidence of Identity by way of
.

Doc. No.

Page No.

Book No.

Series of

, affiant exhibited to me
issued at

on