REPUBLIC OF THE PHILIPPINES )

CITY OF ILOILO )S.S

AFFIDAVIT OF LOSS

I, ________________, Filipino, of legal age, single, and with postal address at

Gerona St. Guimbal, Iloilo, Philippines, after being duly sworn in accordance with law,
depose and state:

1. That I am the ______ of _____________, a corporation duly organized and

existing under and by virtue of the laws of the Republic of the Philippines;

2. That being given the above-mentioned position, it is my responsibility to

receive and keep in my custody the receipts issued by ________ in favor of
_______;

3. That sometime in June 2019, the original copy of the following receipts:

 PR ______

could not be found and that despite of diligent search and efforts, the same
could no longer be located such that I now believe that it is now lost beyond
recovery.

4. As such, I am executing this Affidavit of Loss to attest to the truth of the

foregoing and for whatever legal purpose that this may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this _____ day of ____
2020 at Iloilo, Philippines.

ABD
Affiant

SUBSCRIBED AND SWORN to before me, this ____ day of _______ 2020 by the
Affiant whom I have identified through competent evidence of identity and who
exhibited his _____________ issued at _______ on ___________.

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 2020