REPUBLIC OF THE PHILIPPINES)

CITY OF BAGUIO ) S.S.

AFFIDAVIT OF LOSS

I, VIENDO PALERMO RACOMA, Filipino, of legal age, married, with residential address at #3 J. De Placensia Barangay 6 Lucban

Quezon after having been duly sworn in accordance with law, depose and state:

1. That sometime in April 2021, me and my family transferred from Baguio City to Quezon Province;

2. To my knowledge, I kept the Receipt of our TCL Android TV which I purchased from SM Appliance Store on April 2021 at home

on top of a cabinet;

3. That sometime on November 2022, I went looking for the Receipt and cannot find it despite efforts to look for the same and I am

in belief that it is beyond recovery;

3. That I am executing this affidavit to be issued a Certificate of Purchase by the SM Appliance Store for the warrantee of the TCL

Android TV;

4. That I am executing this affidavit to attest to the truth of the foregoing, and for whatever legal purpose this may serve.

VIENDO PALERMO RACOMA

Affiant

SUBSCRIBED AND SWORN TO before me this 1st day of December 2022, by the affiant who exhibited to me a competent proof of

identity and who attested to the truth of the foregoing statements.

WITNESS MY HAND AND SEAL.

Doc. No. _______;

Page No. _______;

Book No. _______;

Series of 2022.