Republic of the Philippines

Department of Justice
PUBLIC ATTORNEY’S OFFICE
Catbalogan District Office
Catbalogan City, Samar
______________________________________________________________________

Republic of the Philippines…………)

Province of Samar………………….)s.s.
City of Catbalogan……………… …)

AFFIDAVIT

I, ______________ 40 years old, married, and a resident of Purok 1, Brgy.

06 Poblacion, Catbalogan City, Samar, after having been duly sworn in
accordance with law, hereby depose and say:

1. That on January 2, 2019 at around 12:30 in the morning, our house was
gutted with fire for reasons we do not know;

2. That during that time, I together with my family is in our house;

3. That our two-storey house was made of light and concrete materials;

4. That the items that were damaged include, among others, two electric
fans,kitchen utensils, clothings, refrigerator, and other important
documents. Our house was totally damaged;

5. That if our loss due to said fire will be quantified, it would amount to more
or less Eighty Thousand Pesos (P80,000.00);

6. That I am executing this Affidavit in order to attest to the truth of the above
statements and for whatever legal purpose this may serve.

IN WITNESS WHEREOF, I have affixed my signature this ______2019 in

Catbalogan City, Samar.

___________________
Signature over Printed Name of Affiant

SUBSCRIBED AND SWORN to before me this __________ 2019 at

Public Attorney’s Office, Catbalogan City District, Catbalogan City, Samar,
Philippines.