REPUBLIC OF THE PHILIPPINES)

Province of Davao del Norte. . . . . . ) Sc.

City of Tagum. . . . . . . . . . . . . . . . . )
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AFFIDAVIT OF LOSS

I, MELLANI G. ALINSONORIN, of legal age, Filipino, married and a resident of 1017

Purok Bulaklak3, Magugpo North, Tagum City, Philippines, after having been duly sworn to in
accordance with law, do hereby depose and say that:

I am an employee of the Provincial Government of Davao del Norte duly assigned to the
Provincial Governors Office (PGO) as Administrative Assistant VI;

As such employee, it is part of my function to ensure that documents are complete

including the liquidation and settlement of all the financial accounts of the Office;

On March 8, 2017, I received the original copy of the Billing Statement dated May 23,
2016 issued by the Davao del Norte Government Officials and Employees MPC Cooperative
with an amount of Four Thousand Pesos (P 4,000.00) is for process, however, the same was
misplaced and lost from my possession;

Despite diligent search and efforts to locate it but the same could not be found such that I
believe that it is now lost beyond recovery;

I execute this affidavit to attest to the truth of the foregoing facts and to inform the proper
authorities concerned regarding its loss.

IN WITNESS WHEREOF, I hereunto affix my signature this 8th day of March 2017 at
Tagum City, Davao del Norte, Philippines.

MELLANI G. ALINSONORIN
Affiant

SUBSCRIBED AND SWORN to before me this 8th day of March 2017 at Tagum City,
Davao del Norte, Philippines. Affiant exhibited to me her employee identification card having ID
No. 1056 and issued by the Province of Davao del Norte, Philippines.

Doc. No. _____;

Page No. _____;
Book No. ____;
Series of 2017.