REPUBLIC OF THE PHILIPPINES)

CITY OF CALOOCAN )S.S.

AFFIDAVIT OF LOSS

I, ___________________________, of legal age, Filipino and with residence

and postal address at ____________________________________, after having duly
sworn to in accordance with law, hereby depose and state:

1. That I was in possession of one (1) Delivery Receipt with No.

0001451 dated July 30, 2019 issued by Das Arts Plastic Sign SVC CO;
2. That the said Delivery Receipt was lost and/or missing;
3. That I cannot recall whether the said Delivery Receipt was misplaced
or I accidentally dropped or left outside somewhere else or in places
that I had been;
4. That I diligently searched for the missing Delivery Receipt and made
inquiries with people who might have seen the missing Delivery
Receipt but all the efforts proved futile as I can no longer locate the
said Delivery Receipt and the same is now beyond recovery;
5. That I am executing this affidavit to attest to the truth of the foregoing
facts and for whatever legal purpose/s it may serve best.
AFFIANT SAYETH NAUGHT.

________________
Affiant

SUBSCRIBED AND SWORN to before me this 9th day of January 2020 at

Caloocan City, Metro Manila. Affiant exhibited to me his ID No. ___________________.

Doc. No._____________
Page No.____________
Book No.____________
Series of 2020