REPUBLIC OF THE PHILIPPINES)

City of Digos ) S.S.

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AFFIDAVIT OF LOSS

I, _______________________ of legal age, Filipino, married and a

resident of Matanao, Davao del Sur, Philippines, after having been duly sworn to in
accordance with law, do hereby depose and say:

1. That I am the same and identical person who caused the execution of the
foregoing instrument/ affidavit;

2. That I am holder/possessor of the lost AUTHORITY TO PRINT (ATP) for

Politician and the Official Receipt No.01-50, constituting Booklet issued to
me by Bureau of Internal Revenue;

3. That sometime in the year 2018, I was looking for my AUTHORITY TO

PRINT and the said Booklet in my house when I noticed that the same
were missing in my possession;

4. That diligent effort was exerted to locate it but until present the same
prove futile and nowhere to be found. Hence, considered lost for all
intents and purposes;

5. I hereby affirm and confirm that the foregoing allegations are true and
correct and this affidavit is executed to inform of the foregoing allegations
and for whatever legal purpose/s may serve best.

WITNESS WHEREOF, I have hereto affixed my signature this

_____________ at _________________.

_______________________
Affiant

SUBSCRIBED AND SWORN to before me this _____________ at

_________________, affiant is personally identified by me, known to me and
known to be the same person who caused the execution of the foregoing.
WITNESS MY HAND AND SEAL