Republic of the Philippines)

Calapan City ) S.S.

AFFIDAVIT OF LOSS

I, X, of legal age, Filipino, single and with residence and postal

address at Victoria, Oriental Mindoro, after having been sworn to in
accordance with law, hereby depose and state that:

1. On May 20, 2021, when I secured a performance bond in

2. That, I exerted earnest efforts to locate and retrieve the
same, but all our efforts have been proven to be futile and
up to the present, the said receipt could not be found;

3. Thus, I am executing this Affidavit to attest to the truth of

the foregoing and for whatever lawful purpose this may
serve best.

IN WITNESS WHEREOF, I have hereunto set my hand this

_________________________ at Calapan City, Philippines.

__________________
X
Affiant
DL: DO5-

SUBSCRIBED AND SWORN TO before me this _____________ at

Calapan City, Philippines. The affiant being personally known to me
and to me known to be the same person who executed the foregoing
instrument freely and voluntarily

NOTARY PUBLIC

Doc. No. _____

Page No. _____
Book No. _____
Series of 2021