Republic of the Philippines )

Province of _____________) S.S.

City of _________________)
X --------------------------------x

AFFIDAVIT OF LOSS AND DAMAGE TO BUILDING BY FIRE

I, Fr. Marvin O. Osmena, of legal age, Filipino, single and a resident of Immaculate Conception
Cathedral Parish, Ozamiz City, after being worn in accordance with law, depose and state:

1. That I am the Manager/priest-in-charge of CFC building owned by the Roman Catholic

Archbishop of Ozamis, Inc., a duly registered corporation sole;

2. That the said building maintains an office at Cathedral Compound, Valconcha St.,
Ozamiz City, Philippines;

3. That same building occupied ___________, renting its office for engagement of its
business;

4. That sometime on July 30, at around 1:05 in the morning, a big fire broke out somewhere
in the building where the said office was located which destroyed, burned, damaged and
spoiled many of the assorted stocks, merchandise and pertinent documents stored in the
said office and shop, itemized in a separate sworn statement attached hereto as Exhibit A;

5. That the said fire was controlled and put off only about ____ hours later by the efforts of
the different fire brigades and volunteers which responded to our call for assistance;

6. That I am executing this Affidavit to attest to the truth of the foregoing and in support of
the company’s claim on the fire/building insurance of the said building.

IN WITNESS WHEREOF, I have hereunto set my hand this ____________ at the City of
_________________, Philippines.

FR. MARVIN O. OSMENA

Affiant