REPUBLIC OF THE PHILIPPINE)

CITY OF GENERAL SANTOS) S.S.

x- - - - - - - - - - - - - - - - - - - - - - - - - - - x

AFFIDAVIT OF LOSS

I, ANITA BUYCO ACUESTA, of legal age, Filipino, married and a

resident of Purok 5, Lanton Apopong, General Santos City, after having been
duly sworn to in accordance with law do hereby depose and say:

1. That I am a holder of Privilage Card identification card issued by the

FITMART Supermarket of General Santos City;

2. That said privilege card was misplaced while in my possession

sometime on October 10, 2015, and all efforts exerted to locate said
privilege card proved futile as it could no longer be found and is now
considered lost.

3. That I am execute this affidavit to attest to the truth of the foregoing

facts and for whatever purpose this may legally serve.

IN WITNESS WHEREOF, I have hereunto set my hand this 20th day of

October 2015 at General Santos City.

ANITA BUYCO ACUESTA

Affiant

SUBSCRIBED AND SWORN to before me this 20 th day of October 2015 in

General Santos City. Affiant identified by me through her PRC Id No. 0131711,
bearing her photograph and signature.

Doc No. 367;

Page No. 74;
Book No. I;
Series of 2015.