REPUBLIC OF THE PHILIPPINES )

CITY OF MANILA ) S.S.

AFFIDAVIT OF LOSS

I, CIPRIANA G. DELA PEÑA, Filipino, of legal age, with office address at 1770-1774
Instruccion Street corner N.S Amoranto Avenue, Sampaloc Manila, after having been
sworn in accordance with law hereby depose and state:

1. That I am the Treasury Assistant of the Company, Central Affirmative

Co., Inc. and has custody of the receipts kept by the company;

2. That sometime last May, I lost the Security Deposit Receipt of the
Company-owned store located at Robinsons Pulilan dated 2015 while I
was organizing my filing cabinet;

3. That the total Security Deposit is amounting to PhP 49,549.50;

4. That diligent efforts to locate the same proved futile;

5. That I am executing this affidavit to attest to the foregoing facts and as

proof that Security Deposit amounting to PhP 49,549.50 was deposited
with Central Affirmative Co., Inc.

IN WITNESS WHEREOF, I have hereunto set my hand this __ day of _____________in

the City of Manila.

CIPRIANA G. DELA PEÑA

Affiant

SUBSCRIBED AND SWORN to before me, this ____ day of __________in _________
City, with affiant exhibiting his SSS No. 02-2081555-4.

Doc. No. : ________;

Page No. : ________;
Book No. : ________;
Series of 2021