REPUBLIC OF THE PHILIPPINES)

Davao City

) SS.

AFFIDAVIT OF LOSS
I, ROSALINA G. HERNANDEZ, Filipino citizen, of legal age, married, and a
resident of Mc Arthur Highway, Toril, Davao City, after having been duly sworn in
accordance with law, hereby depose and say:
1. that I am the holder of Raffle Ticket No. 0337 for a raffle draw organized by
the Davao City Cooperative Development Council;
2. that during the Raffle Draw, the said raffle ticket was picked for a consolation
prize;
3. that sometime this month, I discovered that said raffle ticket was missing and
despite diligent search, the same could not be found;
4. that I am executing this affidavit to apprise the authorities on the true facts of
the circumstances in connection with the lost raffle ticket and to authorize Ms.
Cornelita Escamis to claim the prize on my behalf.
IN WITNESS WHEREOF, I have hereunto affixed my signature this 10th day of
September 2013 in Davao City, Philippines.

ROSALINA G. HERNANDEZ
Affiant

SUBSCRIBED AND SWORN before me this 10 th day of September 2013, by

ROSALINA G. HERNANDEZ who exhibited to me her ___________________ issued on
________________ at ______________________.
Doc. No. .........:
Page No. .........;
Book No. .........;
Series of 2013.