Republic of the Philippines }

Province of }
Municipality of } S.S

AFFIDAVIT OF LOSS

I, ALEXIS L. ORTIZ, of legal age, Filipino citizen, married, and with postal and
residence address at Matacla, Goa, Camarines Sur, Philippines after having been duly
sworn to in accordance with law hereby voluntarily depose and say:

1. That I am the proprietor of DON MARTIN GROCERY located at San Jose

St., Goa, Camarines Sur;
2. That the Printer’s Certificate of Delivery of the above mentioned establishment
got loss believing it was misplace and cannot found into a cabinet where I put it
in after the establishment stop the operation;
3. That I exerted utmost effort to locate above mentioned PRINTER’S
CERTIFICATE OF DELIVERY but to no avail and now consider as lost and
beyond recovery;
4. That I hereby attest to the truth of the foregoing facts, which I am willing to testify
before any court of justice to substantiate the truth of each and all of the above
said facts and to whatever legal purpose it may serve.

IN TRUTH WHEREOF, I have hereunto signed my name below this October 12,
2023 at Goa, Camarines Sur, Philippines.

ALEXIS L. ORTIZ
Affiant

SUBSCRIBED AND SWORN to before me this October 12, 2023, at

Doc. No.
Page No.
Book No.X;
Series of 2023.