REPUBLIC OF THE PHILIPPINES..….

)
PROVINCE OF___________________..) S.S.
CITY OF ____________…….…………..)

AFFIDAVIT OF LOSS

I, ___________, of legal age, Filipino, married with business

address at ___________________________________________________,
under oath, hereby states:

1. I am ________________________________. In line with my

position, I applied for ___________________________under my
name in favor of our branch office at CAAP;

2. ___________ issued an official receipt relative to the

downpayment or deposit on the new electrical connection
with ____________;

3. That sometime in June 2018, when sorting files in our

cabinet in the office, I discovered that said original copy of
the receipt issued was lost;

4. Diligent efforts to locate the said receipt were made but

same proved fruitless, and I now treat the receipt to be lost
beyond recovery;

5. I am executing this affidavit to establish the fact of the loss

of the above-mentioned NORECO II receipt and request the
NORECO II to issue a certified true copy of the same in lieu of
the lost one, and for whatever legal purposes it may serve
best.

Affiant sayeth naught.

IN WITNESS THEREOF, I have hereunto set my hand this 19th

day of March 2019 in Dumaguete City, Negros Oriental,
Philippines.

________________
Affiant

SUBSCRIBED AND SWORN to before me this ____________in

___________, Philippines.
Doc. No. ___;
Page No. ___;
Book No. ___;
Series of 2019.