Republic of the Philippines)

City of Davao ) s. s

AFFIDAVIT OF LOSS

I, ______________________, of legal age, married, Filipino, and residing at

___________________________, _________ City, after having been duly sworn, hereby
depose and state: That---

1. I am the owner of _______________ with business address at __________________;

2. Sometime on ___________, due to flood, various documents were damaged;

3. The ________________________ could not be found despite diligent search and efforts;

4. Sales Invoices, Official Receipts, Vouchers and other documents were destroyed and/or
lost;

5. Diligent efforts were exerted to retrieve or locate the aforesaid documents and records but
to no avail;

6. I am executing this affidavit to attest to the truthfulness of the foregoing statements and for
whatever legal purpose this may serve best.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

________________ at ____________________________, Philippines.

Doc. No. ___

Page No. ___
Book No. ___
Series of 2023