Republic of the Philippines )

Province of Camarines sur ) S.S.

Municipbality of Libmanan )

AFFIDAVIT OF LOSS
I, ____________________, of legal age, married, Filipino and a resident of
Arimbay, Legazpi City, after having been duly sworn to in accordance with law, hereby
depose and state:

1. That I am the bondsman of _________________, the accused and provisionally

dismissed in Criminal Case No. _________________ for Qualified Theft before
the Regional Trial Court Branch 57, Libman, Camsur;

2. That for his provisional liberty I posted a Cash Bond in the amount of TWENTY-
FOUR THOUSAND PESOS (Php 24, 000.00) with an Official Receipt No.
____________ dated August 24, 2011 issued by the Office of the Clerk of Court,
RTC, Libmanan, Camarines Sur;

3. That on ___________________, I just notice that said Official Receipt can no

longer be found from where I have place it despite my honest and diligent efforts
to locate the same;

4. That said Official Receipt was misplaced and is deemed lost;

5. That I am executing this Affidavit to attest the truth of the foregoing statements and
to request the Office of the Clerk of Court, RTC, Libmanan, Camarines Sur, to
issue a copy of Official Receipt for legal purpose that this may serve;

Affiant further sayeth naught.

IN WITNESS WHEREOF, I have hereunto set my hand this 24 th day of August 2017
at Daraga, Albay.

_____________________
Affiant
SUBSCRIBED AND SWORN TO before me this 24th day of August 2017 at Daraga,
Albay by the affiant who exhibited to me his _______________ as competent evidence
of identity in accordance with Rule 2, Section 12 (a) of 2004 New Rules on Notarial
Practice, as amended.
Doc. No. ____:
Page No. ____:
Book No. ____:
Series of 2017.