REPUBLIC OF THE PHILIPPINES)

CITY OF MANILA ) s.s.

AFFIDAVIT OF LOSS

I, Filipino, single, of legal, age and with postal address at Valencia Street, Pumping
Station Sta. Mesa, Manila, after having been subscribed under the Law, do hereby depose
and state that:

1. Sometime October 2016 , I purchased a TELEVISION SET, 32 inches at SM

APPLIANCES CENTER, located at SM Centerpoint, Sta. Mesa, Manila, more
particularly described as follows:

MODEL NO. SERIAL NO.

for which I was issued an OFFICIAL RECEIPT (OR);

2. Unfortunately, while I was searching for the said OFFICIAL RECEIPT (OR) at
my residence, I discovered that the same was already lost/missing.

3. Despite deliberate my effort to recover the said Receipt OFFICIAL RECEIPT

(OR), all my efforts proved futile since the same was no where to be found and
should therefore be considered lost.

I am executing this affidavit to attest to the truth of the foregoing and for what ever
legal purpose this may serve.

IN WITNESS WHEREOF, I have hereunto affix my signature on this July 24, 2017
at the City of Manila.

Affiant

SUBSCRIBED AND SWORN to before me this 24th day of July 2017, at the City
of Manila

Doc. No: 470

Page No: 95
Book No: 21
Series of 2017