Republic of the Philippines )

Davao del Norte ) S.S.

City of Tagum )
x--------------------------------------------x

AFFIDAVIT OF LOSS

I, Naomi L. Enerio, of legal age, Filipino, married, and a resident of

Bermudez, Apokon, Tagum City, Davao del Norte, under oath depose and
say that:

1. Sometime on the first week of March of the year 2017, my son,

Yan-Ae L. Enerio, lost my Harvest Ingathering Receipt with receipt
number 6245 with the amount of One hundred pesos, when he
brought the solicitation receipt with him in school;

2. Despite repeated diligent search, I and my son could not locate

the same and I believe that the same is lost beyond recovery;

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

statements, to apprise the proper authorities, and to facilitate the
issuance of a new Harvest Ingathering Receipt to replace the one’s
I have lost.

IN WITNESS WHEREOF, I have hereunto affixed my signature this

_____th day of March, 2017 at Tagum City, Davao del Norte, Philippines.

Naomi L. Enerio
Affiant

SUBSCRIBED AND SWORN to before me on this ____ day of March,

2017 affiant exhibiting to me sufficient evidence of his identity.

Witness my hand and seal.

Doc. No.: ___________;

Page No.: ___________;
Book No.: ___________;
Series of 2017.