REPUBLIC OF THE PHILIPPINES)

CITY OF MALOLOS, BULACAN)S.S.

AFFIDAVIT OF LOSS

I, ___________________________, single/married, Filipino, of legal age with residence

and post-office address at _______________________________, having been duly sworn to in
accordance with law, hereby depose and say;

That I am the __(Position in the Business) ___________ of JD DIAGNOSTIC located at

________________________________;

That I am a holder of Landbank Check in the sum of P____________ issued under

the name of JD DIAGNOSTIC having Check No. 0000242554 dated September 29, 2023
issued by _______________________ as payment for Materials;

That the said Landbank Check in the sum of P____________ issued under the name
of JD DIAGNOSTIC having Check No. 0000242554 dated September 29, 2023 was lost in
my possession for unknown reason;

That I exerted all my effort to locate and find the same prove futile and to no avail;

That I execute this affidavit to attest to the truth and the veracity of the foregoing fact that
the above-mentioned was lost due to the above-cited reason and to inform the concern office
regarding the said incident and for all legal intents and purposes this may serve best;

IN WITNESS WHEREOF, I have hereunto set my signature this ____ day of 2023 at
Malolos City, Bulacan;

__________________
Affiant

SUBCRIBED AND SWORN to before me this ____ day of Malolos City, Bulacan.
Affiant personally known to me and/or identified through competent evidence of identity as the
person who executed and signed the document in my presence and exhibited to me his

Doc. No. ___;

Page No.___;
Book No.___;
Series of 2023