Republic of the Philippines )

City of Taguig, Metro Manila) S.S.

AFFIDAVIT OF LOSS

I, VERGEL D. JAMON, of legal age, Filipino citizen, with residence and postal address
at Diezmo Road Pulo, Cabuyao, Laguna, after having duly sworn to in accordance with law do
hereby depose and state:

That I am a holder and in possession of the following items:

1. Tracker’s copy of a Delivery Receipt with Numbers 211852, 211853,

211854, 211855, 211856, and 211857 issued by Green Cross Incorporated,
located at 2150 Iba St., United Paranaque Subd. I, Paranaque City, covering
the items delivered to SUPER SHOPPING MARKET INC. - BATANGAS
dated April 22, 2014;
2. Tracker’s Copy of a Sales Invoice with Numbers 1093644, 1093645,
1093646, 1093647, and 1093648, issued by Green Cross Incorporated,
located at 2150 Iba St., United Paranaque Subd. I, Paranaque City, covering
the items sold to 256 Mercury- Sta. Cruz P. Guevarra, P. Guevarra St., In
Front of Capitol, Sta. Cruz Laguna dated April 22, 2014;

That on April 23, 2014, while looking for the aforesaid items, in the envelop where it
was usually kept, I could no longer find the same, probably was misplaced;

That I exerted all efforts to locate or find the said YELLOW and GREEN copies of Sales
Invoice, but proved futile and meaningless whatsoever;

That I am executing this AFFIDAVIT to attest to the truth and veracity of the above
statements for all LEGAL INTENTS and PURPOSES it may serve best.

IN WITNESS HEREOF, I have hereunto signed my name this 30 th day of June 2014 at
City of Taguig, Metro Manila.

VERGEL D. JAMON
Affiant

SUBSCRIBED & SWORN TO BEFORE ME this 30th day of June 2014 at City of Taguig,
Metro Manila, affiant exhibiting to me PHILHEALTH ID Card No. 08-050894579-9.

Doc. No. ____

Page No. ____
Book No. II .
Series of 2014.