REPUBLIC OF THE PHILIPPINES)

CITY OF __________________)

AFFIDAVIT OF LOSS

I, ROBERT CYRILL G. REGENCIA, of legal age, Filipino Citizen, and with

the address at 19F Domingo Guevarra St. Highway Hills, City of
Mandaluyong,2nd District, NCR, Philippines after being duly sworn in
accordance with law, do hereby depose and say:

1. That I am the owner of an AIC Burgundy Empire Tower Inc. Official

Receipt with provisional receipt dated September 2021 for Pricemart
Philippines Corporation;

2. That the Official Receipt is amounting to fifty thousand pesos

(P50,000) which serves for both parties’ construction bond;

3. That I have given my fullest effort to look for the item lost and
misplaced by me but it can no longer be found;

4. That I am executing this affidavit to attest to the fact of my loss and

for whatever legal purpose this may serve.

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

_____________, 2023 at __________________, Philippines.

_________________________
ROBERT CYRILL G. REGENCIA

SUBCRIBED AND SWORN to before me this _____ day of _______, 2023

at ____________________, Philippines, affiant exhibiting to me his TIN with
number 433-713-557-000 exhibiting his signature.

DOC: _____ NOTARY PUBLIC

PAGE: _____
BOOK: ____
SERIES OF 2023