Republic of the Philippines)

Province of Quirino)
Municipality of Diffun)s.s.

AFFIDAVIT OF LOSS

KNOW ALL MEN BY THESE PRESENTS:

I, FERNANDO P. SIMODIO, of legal age, Filipino, married,

and a resident of Liwayway, Diffun, Quirino, after having been
sworn in accordance with law, hereby deposes and states the
following:

1. That I am a Truck aide employee of Philippine Spring Water

Resources. InC.
2. That there is Collection Receipt/OR they give to me with the
series of 34442-34450;

3. That sometime on JUNE 11 2019, I noticed that the said

Collection Receipt/OR was missing when I forgot it to the
customer;

4. That to my knowledge, the said Collection Receipt/OR was lost;

5. That I took great pains to look for the said Collection

Receipt/OR but no avail;

6. As such, I am executing this affidavit to attest to the foregoing

facts and statement.

7. IN WITNESS WHEREOF, I have hereunto set my hand this

17thday of June, 2019 at Diffun, Quirino, Philippines.

FERNANDO P. SIMODIO
Affiant
Company ID NO. 26211782

SUBSCRIBED and SWORN TO before me on the date and at

the place indicated below. The affiant exhibited to me his competent
evidence of identity as indicated above.

Signed this 17thday of May, 2019 at Diffun, Quirino, Philippines

WITNESS MY HAND AND SEAL.