Republic of the Philippines )

City of -- ) S.S
X ------------------------------ X

AFFIDAVIT OF MUTILATION/DESTRUCTION

I, ___, of legal age, single, and a resident of ---, after having duly sworn to
an oath hereby declare:

That I am the Branch Manager of --------------;

That one of the documents stored in our office at xx Branch are ______
FORMS which are kept for filing and recording;

That the said ---- FORMS were placed inside the cabinet of our office for
safekeeping. Unfortunately, when we had our general cleaning on the premises, I
discovered that some of the used -- Forms for the period August 2020 to
December 2020 were damaged as some parts were eaten by termites;

That the damage on the said used --- Forms for the period of August 2020
to December 2020 has rendered it unusable and unreadable;

That I am executing this affidavit to attest to the truth of the foregoing

facts and for whatever legal purposes and intents this may serve.

IN WITNESS WHEREOF, I have hereunto affixed my signature this

__________________, at _____, Philippines.

_____________
Affiant

Signed in the presence of:

SUBSCRIBED AND SWORN TO BEFORE me this

______________, at _____, Affiant having presented his __________valid
ID with number _______________________ as her competent evidence of
identity.