Republic of the Philippines)

City of Tacloban ) s.s.

Province of Leyte )
x-------------------------------x

AFFIDAVIT OF LOSS
(O.R.)

I, GUSTAV CZAR Y. JOMADIAO, of legal age, single, Filipino and a

resident of Brgy. San Vicente, Alangalang, Leyte after having been duly sworn
to in accordance with law do hereby depose and say;

1. That I am the proprietor of EBJ Builders and Enterprises which

business address located at Brgy. San Vicente, Alangalang, Leyte;

2. That relative thereto, I have produced Receipts No. 0001-2500 for

issuance to my customers;

3. That unfortunately, Booklet #1 with Receipts #0001-0050 was lost

then Booklet #2 was initially used.

4. That I had made diligent efforts to locate said Booklet #0001-0050,

but the same have proven futile, hence, for all intent and legal purposes I
considered it lost and beyond recovery;

8. That I am executing this affidavit to attest the truth and veracity of

all the foregoing statement.

IN WITNESS WHEREOF, I have hereunto affix my signature this 22 th day

of July 2016 at Tacloban City.

GUSTAV CZAR YAP JOMADIAO

Affiant

SUBSCRIBED AND SWORN to before me this 22th day of July 2016 at

Tacloban City. Affiant exhibited to me her TIN CARD with No.464-353-139.

Doc. No. ____

Page No. ____
Book No. ____
Series of 2016