REPUBLIC OF THE PHILIPPINES )

PROVINCE OF NORTHERN SAMAR )S.S.

MUNICIPALITY OF CATARMAN )

AFFIDAVIT OF LOSS

I, __________________, of legal age, Filipino, and residing at

Brgy. Washington, Catarman, Northern Samar, Philippines, after being sworn
to in accordance with law, depose and say:

That I am a Teacher at Tinowaran Elementary School, thus I was task

to supervise and take care properties of the school, such as but not limited
to the following:

1. 15 pcs Araling Panlipunan Learner’s Materials 4;

2. 1 pc Mathematics Learner’s Materials 4;
3. 1 pc Science Learner’s Materials 4;
4. 5 pcs English Learner’s Materials 4;
5. 5 pcs EPP Learner’s Materials 4;
6. 5 pcs MAPEH Learner’s Materials 4;
7. 5 pcs E.S.P Learner’s Materials 4;
8. 12 pcs Filipino Learner’s Materials 4;

That the above-described books were unfortunately damaged during

typhoon Nona last December 2015;

That despite of diligent efforts to save and retrieve said items, I could
not do so;

As such, I am executing this Affidavit of Loss to attest to the truth of

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

IN WITNESS WHEREOF, I have hereunto set my hand this

________in the Municipality of Catarman, Province of Northern Samar,
Philippines.

______________________
Affiant

SUBSCRIBED AND SWORN to before me this ___________, in

Catarman, Northern Samar, Philippines, by affiant, known to me to be the
same person who executed and personally signed the foregoing instrument
before me and avowed under penalty of law to the whole truth of the
contents of said instrument.

Doc. No._____;
Page No._____;
Book No._____;
Series of 2016.