Republic of the Philippines

Province of Leyte
Municipality of Palo

AFFIDAVIT OF LOSS
I, ENGR. ELIAS B. CACA, of legal age, married, Filipino, and a resident of Brgy.
Zone 1 Sta. Fe, Leyte, after having been duly sworn to in accordance with law, hereby
depose and say, THAT:

1. I am the proprietor of a business establishment with business name

SKYMIX GENERAL MERCHANDISE situated at Brgy. Zone 1 Sta. Fe,
Leyte;

2. The said establishment was duly registered with the Bureau of Internal
Revenue (BIR) with Tax Identification No. (TIN) 906-622-789-000, as
such, said business had printed booklets of receipts;

3. Unfortunately, I discovered that the Official Receipts numbered 001 to

0150 (booklet No. 1 to 3) were lost/missing;

4. It could have been misplaced/ played with by the kids considering that
the same establishment had closed/ceased its operation sometime in
February 20, 2017;

5. Despite diligent effort to save and retrieved the above-mentioned receipts,

my effort proved futile;

6. Said receipts were neither confiscated for any violation of law, rules and
regulations;

7. I am executing this Affidavit in order to attest the fact and truthfulness of

the foregoing statements and for whatever legal purpose this may serve.

IN WITNESS WHEREOF, I hereunto set my hand this 2 nd day of May 2019 at

Palo, Leyte, Philippines.

ELIAS B. CACA
Affiant
Personally known

SUBSCRIBED and SWORN TO BEFORE ME this 2nd day of May 2019 at Palo,
Leyte, Philippines, affiant exhibited his Identification card shown above.

Doc: 266
ATTY. SHARON R. VILLONES
Page: 55 Notary Public
Book: III N.C. No. 2019-01-53 until December 2018
Series of 2019 IBP Lifetime No. 017319
Roll No. 67394/May 24, 2017
PTR No. 2613151/Jan 16, 2019/Palo, Leyte
Kertz Apartment, Fatima Village
Brgy. 77 Marasbaras, Tacloban City 6500