AFFIDAVIT OF NON-RECEIPT OF CASH DIVIDEND CHECKS

Republic of the Philippines)

……………………………) S.S.

I, …………………………………………….. of legal age, Filipino, married, a resident of

(full name)

………………………………………………….. after having been duly sworn in accordance with law, do

hereby depose and say:
That I am a stockholder of PETRON CORPORATION, and am entitled to dividends that may be declared by
the Board of Directors of Petron Corporation;
That to date, I have not received nor have I authorized any person to receive the following cash dividend
checks:
Payment Date Check Number Amount

That I have not presented for encashment any of the above-mentioned cash dividend check(s) nor have I
caused the negotiation thereof in favor of third parties;
That I now consider said cash dividend check(s) as lost and request Petron Corporation for the replacement
thereof, further authorizing Petron Corporation to instruct the issuing bank to stop payment of the cash
dividend check(s) which are now considered lost;
That, upon this request, I agree to render assistance to Petron Corporation by way of the execution of
documents necessary for the recovery of the full amount of the above check(s) in case the same is found to
have been presented for payment or negotiated at any bank; Provided, however, that if the payment or
negotiation of the original check(s) was due to my negligence or with my consent or authority, I agree to
reimburse Petron Corporation for the full value of the check(s) plus legal interest.
That, upon receipt and payment of the replacement check(s), I hereby agree to the release of Petron
Corporation and its officers and employees from any claims or liability for costs, and damages arising from or
in connection with the issuance of the original as well as, of the replacement check(s).
That this Affidavit has been executed to attest to the truth of the foregoing and in support of my request for
Petron Corporation to replace the lost cash dividend check(s).
IN WITNESS WHEREOF, I have signed these presents in ………………………………………….
Philippines, this …………. day of ………………………, 20………

…………………………………..
AFFIANT

SUBSCRIBED AND SWORN to before me, in ….…………………………………….., Philippines, this

………… day of ……………… , 20…… affiant having exhibited to me his/her Residence Certificate A-
………………………….., issued at ……………….. on ………………………. , 20 ………

NOTARY PUBLIC
Until December 31, 20 ………..
Doc. No. ……………
Page No. …………...
Book No. …………..
Series of 20 ………..