REPUBLIC OF THE PHILIPPINES)

City of Ormoc ) S.S.

x-------------------------------------------x

AFFIDAVIT OF LOSS
I, DANTE PAREJA MANATAD, Filipino, of legal age, a member of the Philippine National Police
(PNP), and a resident of Barangay Valencia, Ormoc City, Leyte, after having been sworn in
accordance with law hereby depose and state THAT:

1. I am tasked as a purchaser at the Ormoc City Police Office. Previously, I was tasked to
purchase meals and snacks which was taken from the funds of the City Mayor’s Office, and
was tasked to process PURCHASE REQUEST with No. 221961, PURCHASE ORDER with No.
221051, dating September 27 2022 – amounting to 950,000.00;

2. On November 10, 2022, the following documents were in my possession to process the
abovementioned Purchase Request and Purchase Order:

a. Original Purchase request

b. Original Purchase order
c. Certification of Appropriation, Funds and Obligation of allotment
d. Abstract of Quotations
e. Notice of Award
f. Request for Quotation
g. Omnibus Sworn Statement
h. Mayor’s Permit
i. Annual Tax Income Return
j. List of Eligibility Requirements for Bidders
k. Office of the Bids and Awards Committee Certification
l. PPMP – Project Procurement Management Plan
m. Philippine Government Electronic Procurement System

3. On November 15, 2022, I was preoccupied with my other tasks while I was processing the
abovementioned Purchase Request and Purchase Order. While I was going from one office
to another, I somehow misplaced the abovementioned documents;

4. Efforts were exerted to locate said documents, but in spite of diligent search, it could not be
found and the same is now beyond recovery;

5. As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing and to
support my application for the issuance of new and original documents in lieu of the ones
lost.

IN WITNESS WHEREOF, I have hereunto set my hand this _________________ in Ormoc City,
Philippines.

DANTE PAREJA MANATAD

Affiant
Driver’s License
H03-99-032691 Expiry 2032 / 8 / 17

SUBSCRIBED AND SWORN to me before this _________________________, affiant exhibited to me his

identity card stated above which serves as competent evidence of his identity.

Doc. No. _____;

Page No. _____;
Book No.______;
Series of 2022.