REPUBLIC OF THE PHILIPPINES)

C I T Y  O F PUERTO PRINCESA) S.S.

AFFIDAVIT OF LOSS

I, ADELA ABASOLO_ of legal age, Filipino citizen, married with residence at

Bgy, San Pedro, Puerto Princesa City, after having duly sworn to in accordance with
the law do hereby depose and say:

That, sometime in 2016, I bought a transformer and had the same installed
by PALECO;

That, prior to such installation, as a matter of policy, I was required by

PALECO to make a deposit in the amount of Php 15,000.00, refundable in three (3)
years;

That, I have paid the said deposit and was issued by PALECO an Official
Receipt with amount indicated as Php 15,000.00 with O.R No. 210769 dated
December 19, 2016;

That, I kept the said official receipt in my home office and not until recently
that I discovered that the same is missing and its whereabouts cannot be
ascertained;

That, despite due and diligent search made and undertaken it can no longer
be found, thus I now believe that the same is lost beyond recovery;

That, I am executing this affidavit to process my refund from PALECO of the

above mentioned deposit amounting to Php 15,000.00;

That each and every fact herein stated is true and I am willing to testify
before any court of justice to substantiate the truth of each and all the said facts.

FURTHER AFFIANT SAYETH NAUGHT.

IN WITNESS WHEREOF, I hereunto set my hand on this ____ day of

_________ in the City of _ Puerto Princesa__.

ADELA ABASOLO
Affiant

SUBSCRIBED AND SWORN to before me on this _____ day of

________________in the City of Puerto Princesa by the affiant who has
satisfactorily proven to me his identity through her Government Issued ID
____________ with number___________ ssued by _______________ on
_______________ and valid until _____________.

Doc. No. Notary Public

Page No.
Book No.
Series of  2020