REPUBLIC OF THE PHILIPPINES )

CITY OF GENERAL SANTOS ) S.S.

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AFFIDAVIT OF LOSS
I, _____________ Filipino, of legal age, married, and a resident of
_______________, Philippines, after being duly sworn in accordance with law, depose and
state, THAT:

1. Sometime in September 17, 2018, I was issued Deposit Acknowledgment Receipt

with details, to wit:

Form No. Issuing Company Description Amount

2. Sometime in June 2019, the said Deposit Acknowledgment Receipt was misplaced
and got lost;

3. Despite diligent search and efforts to locate the said Deposit Acknowledgment
Receipt, I could not find the same such that I now believe that it is now lost beyond
recovery;

4. The said Deposit Acknowledgment Receipt was not confiscated by any officer of any
Government Agency or officer of the law for violation of any law, ordinance,
presidential decree or rules and regulations;

5. I am executing this Affidavit of Loss to attest to the truth of the foregoing facts and
for the purpose of reimbursement of the amount indicated in the lost Deposit
Acknowledgment Receipt and the acceptance of the photocopy in lieu of the lost
receipt for determination of the exact amount contained therein.

IN WITNESS WHEREOF, I have hereunto set my hand this August 05, 2019 at General
Santos City, Philippines.

______________
Affiant
LTO D/L No.
Expiration Date: 03/11/2024

SUBSCRIBED AND SWORN to before me this August 05, 2019 in the City of General
Santos, Philippines, affiant having exhibited to me his competent means of identification as
indicated above.

Doc No. __;

Page No. 22;
Book No. __;
Series of 2019.