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REPUBLIC OF THE PHILIPPINES

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City of Cebu ) S.S.
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AFFIDAVIT OF LOSS

I, ROMEL STEPHEN BORGONIA, of Legal Age, Filipino, married to Romel
Stephen Borgonia, with residential address at Bacayan, Cebu City, Philippines,
subscribing under oath, hereby depose and state:

1. That sometime on February 2018, I noticed that the Stab No. 2 of the
Official Receipt of Nick Transport Service was missing;

2. That I could not remember where I placed the 2nd stab of unused official
receipts;

3. That I placed all the other Official Receipts that was still unused on top
of our bookshelf in my residence. When I was about to use the 2 nd stab of
the receipt, I could no longer locate it on the bookshelf, however all the
other OR stabs are intact. The only missing stab is “STAB #2”;

4. That I am the driver of a Toyota Vios with Temporary Plate No. VZ 0555
which is owned by Nico Dale Entece doing business under the name of
Nick Transport Service with business address located at Unit 3 Oprra,
Kalunasan, Cebu City;

5. That the details of the BIR Official Receipts that were lost are OR Nos.
0051 to 0100;

6. That despite diligent efforts to locate the same, it could no longer be
located and I declare that this is lost for all legal intent and purpose;

7. I am executing this Affidavit to attest to the truth of the foregoing
narration of facts and for whatever legal purpose it may serve.

FURTHER AFFIANT SAYETH NAUGHT

IN WITNESS WHEREOF, I have hereunto set my hand this 23rd day of
April 2018, in the City of Cebu, Philippines.

ROMEL STEPHEN BORGONIA
Affiant
ID No. ____________
Issued by: ___________
Valid until ____________

SUBSCRIBED AND SWORN to before me this 23rd day of April 2018 at
the City of Cebu, Philippines. That he is personally known to me, he is the same
person who executed this Affidavit and has presented competent proof of
identity.

Doc. No. ____;
Page No. ____;
Book No. ____;
Series of 2018 .

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