REPUBLIC OF THE PHILIPPINES)

CITY OF PARANAQUE ) S.S.

AFFIDAVIT OF LOSS

I____________________, of legal age, Filipino and with office address at

__________________________________., Parañaque City, after having been duly
sworn to in accordance with law, depose and state:

1. That I bought a Hanabishi HJC 18SS Jar Type Rice cooker for Php 1,260;

2. That the rice cooker was bought at SM Hypermarket Bicutan Branch on

______________;

3. That sometime on May 22,2019, I discovered that the Rice cooker has a defect
so I returned the same for SM for service.

4. That as a prerequisite for the claim of the rice cooker, the receipt would have
to be presented. However, upon searching for the receipt, I discovered that
the same was missing;

5. That diligent efforts to locate the same proved futile;

6. That in view thereof, I now desire and hereby request SM Hypermarket to

allow me to claim the rice cooker despite the loss of the receipt.

7. That I am executing this affidavit to attest to the foregoing facts and for any
legal purpose it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this __________day of

July 2019 in Parañaque City, Metro Manila, Philippines.

Affiant

SUBCRIBED AND SWORN TO before me this _______ day of July

2019 in Parañaque City, Metro Manila, Philippines, affiant exhibiting to me his
Driver’s License with no. _____________________ as valid proof of identification.

NOTARY PUBLIC
Doc. No. _____;
Page No. _____;
Book No. _____;
Series of 2019.