Republic of the Philippines)

City of Butuan )S.S.

x-------------x
AFFIDAVIT OF LOSS

Questions were propounded to the affiant in Visayan Language which the affiant fully
understands, while answers were given by him also in Visayan Language and translated into
English in this Affidavit.

Answers were given by the affiant in full consciousness that he does so under oath and
that he may face criminal liability for false testimony or perjury.

I, __________, Filipino, of legal age, and a resident of P-9, Maug, Butuan City, after
being duly sworn in accordance with law, depose and state:
That I was issued a Company ID by the Celebes Coconut Corporation.
That it was lost three (3) days ago; may be I put it somewhere else or it fell in the road
while I went home from work;
As all efforts to find the same proved unrewarding, it is now safe to conclude that
recovery of the same is an impossibility;
Thus, I execute this affidavit to establish its loss and to support my application for the
issuance of a replacement of a new Company ID by the Celebes Coconut Corporation.
IN WITNESS WHEREOF, I have hereunto set my hand this December 6, 2018 at Butuan
City, Philippines.

__________
Affiant

Subscribed and Sworn to before me this December 3, 2018 in the City of Butuan. Affiant
personally known to the undersigned notary public.

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 2018.