REPUBLIC OF THE PHILIPPINES )

CITY OF QUEZON) S.S.

AFFIDAVIT OF LOSS

KNOW ALL MEN BY THESE PRESENTS:

I, MARK LHEVIE V. ALCANTARA of legal age, and residing at 91 ANGELO STREET, LA LOMA,
QUEZON CITY, METRO-MANILA after having been sworn according to law, hereby depose and
state that:

1. I am the owner of the OFFICIAL RECEIPT purchasing

2. I have recently discovered the said document is irretrievably lost and can no longer be

found despite diligent efforts to locate the same.

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

Signed on the date and at the place indicated below.

SUBSCRIBED and SWORN TO before me on the date and the place indicated below. The affiant

exhibited to me his competent evidence of identity as indicated above.