REPUBLIC OF THE PHILIPPINES )

PROVINCE OF PANGASINAN ) S.S.

MUNICIPALITY OF MANGALDAN)

AFFIDAVIT OF LOSS

I, CARLA MAE BENITEZ, of legal age, Filipino, and a resident of Brgy. Guesang, Mangaldan,
Pangasinan, after having been duly sworn in accordance with law, hereby depose and state:

1. That I am presently working at ADVECT MARKETING CORPORATION as an

Accountants Receivable (AR) and issued a Delivery Receipt with following details:

Order No. 730534;

Customer Name: Parking Mart/Aringay;
Invoice Date: 09/26/2022;
Referrence No. 60020116;
Amount: 7,086.24

Note:
Delivered 10/1
NO CANCELLATION
NO B.O

COMPLETE STOCKS RECEIVED

2. That in my capacity as such, I lost the said Delivery receipt duplicate copy under unknown
circumstances;

3. That I exerted diligent effort to locate the said delivery receipt original copy but same provide futile.
Hence, I concluded that it is list beyond recovery and irretrievable lost;

4. That I am executing this affidavit to establish the fact of lost delivery receipt original copy to attest to
the truth of all foregoing facts and whatever legal purpose it may serve.

IN WITNESS WHEREOF, I have hereunto affixed my signature this November 25, 2022 in
Mangaldan, Pangasinan.

CARLA MAE BENITEZ

Affiant
Philhealth ID No. 05-025610091-3

SUBSCRIBED AND SWORN to before me this November 25, 2022 in Mangaldan, Pangasinan.

ATTY. FERNANDO JUAN A. CABRERA

NOTARY PUBLIC
UNTIL DECEMBER 31, 2022 per BM 3795
Doc. No. YDIA ST. BRGY. GUILIG, MANGALDAN, PANG.
IBP No. 0075/1-3-22
Page No. PTR No. 8672591/1-3-22
Book No. ROLL NO. 62453/TIN 429-314-607-000
SNC-NP-15-2020
Series of 2022. MCLE Comp. No. VII-0005380, 10-26-21