Republic of the Philippines )

Mandaue City ) S.S.

AFFIDAVIT OF LOSS

KNOW ALL MEN BY THESE PRESENTS:

I, JOMAR T. ARABIS of legal age, Filipino, single/married, and a resident

of Coast Pacific st., Mahiga creek, Brgy. Kasambagan, Banilad, Cebu City, after
having been sworn in accordance with law, hereby deposes and states the
following that:

1. I am holder and possessor of an official receipt with no. 384723 issued by

the Provincial Treasurer’s office of Cebu on October 8, 2019.
2. I have recently discovered the said official receipt is irretrievably lost
and can no longer be found despite diligent efforts to locate the same;
3. I execute this affidavit to attest to the truth of the foregoing. Signed on
the date and at the place indicated below.

JOMAR T. ARABIS
Affiant
Date:

SUBSCRIBED and SWORN TO before me on the date and at the place

indicated below. The affiant exhibited to me his competent evidence of identity as
indicated above. Signed this _______________________at ________________,
Philippines.

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