Republic of the Philippines )

City of Cebu ) S.s.

AFFIDAVIT OF LOSS
I, __________________, Filipino, of legal age, single/married and a resident of
____________________________, Cebu City, after having been duly sworn to in accordance
with law, hereby depose and state, THAT:

1. I am an employee of __________________________________-;

2. Sometime early this month, I was able to secure orders from Cebu Doctor´s Hospital for
which I issued an acknowledgment receipt from a check payment by the said hospital;

3. Unfortunately, the copy of the acknowledgment receipt was lost sometime on April 11,
2014, together with other personal documents in my possession after they were misplaced
in my residence;

4. Efforts to retrieve the said acknowledgment receipt have proven futile and may now be
considered as beyond recovery;

5. I am executing this affidavit to attest to the truth of the foregoing.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ____ day of

_______ 2018 in the City of Cebu, Philippines.

___________________________
Affiant

SUBSCRIBED AND SWORN TO BEFORE ME this ____ day of ___________ 2018 in

the City of Cebu, Philippines, affiant showed his/her LTO Driver's Lic._____________________
issued in __________ City and expires on ____________.