Republic of the Philippines }

City of _____________ } S.S.

AFFIDAVIT OF LOSS

I, ____________, of legal age, Filipino, with an address at _____________________,

Philippines, after having been sworn in accordance with the law, hereby deposes and states the
following that:

1. Sometime in 2015, I bought a ________________________ and a corresponding official

receipt was issued to me as proof of my purchase thereof and kept the same in my personal
files;

2. However, recently, upon checking my files, the said receipt was nowhere to be found and
despite all diligent efforts in locating the same, such that I now believe that it is now lost
beyond recovery.

3. I am executing this Affidavit of Loss to attest to the truth of the foregoing to enable the
acceptance of the abovementioned item for its much needed repair and for any legal purpose
it may serve.

IN WITNESS WHEREOF, I have hereunto affixed our hands this _____ day of
_______________ at _________________, Philippines.

________________________
Affiant

SUBSCRIBED and SWORN TO before me this _________________________ at

____________________. The Affiant exhibited to me his competent evidence of identity
___________________________________________ issued on __________.

Doc. No.: _____

Page No.: _____
Book No.: _____
Series of 2022.