REPUBLIC OF THE PHILIPPINES)

Province of South Cotabato ) S.S.

Municipality of Polomolok )
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AFFIDAVIT OF LOSS

I, JULIUS KIM V. CARDIÑO, of legal age, Filipino, married, and a

resident of Purok Matulungin, Brgy. Magsaysay, Polomolok, South Cotabato,
Philippines, after having been duly sworn in accordance with law, hereby depose
and state THAT:

1 I am an Assistant Information Officer of the Municipality of Polomolok,

South Cotabato;
2 I was issued an Official Receipt Booklet with series number 0299451 to
0299500;
3 Sometime on November 3, 2015, the pink copy or the duplicate copy of
Official Receipt No. 0299464, issued to Lebanan, Jesus Deogracias
dated October 29, 2015 was misplaced and lost;
4 Despite diligent search and efforts to locate the said duplicate copy of
the aforementioned official receipt, I could not find the same such that I
now believe that it is now lost beyond recovery;
5 As such, I am executing this Affidavit of Loss to attest to the truth of the
foregoing.

IN WITNESS WHEREOF, I have hereunto set my hand this 12 th day of

November 2015 at Polomolok, South Cotabato, Philippines.

JULIUS KIM V. CARDIÑO

SUBSCRIBED AND SWORN to before me, this 12th day of November 2015,
by the Affiant whom I have identified through competent evidence of identity and
who exhibited his Municipality of Polomolok Identification Card No. 0010.

ATTY. ANDRES D. LORENZO III, CPA

Public Attorney II
Pursuant to R.A. 9406