Republic of the Philippines)

City of Tagum )ss.

x - - - - - - - - - - - - - - - -x

AFFIDAVIT OF LOSS

I, ____________, of legal age, Filipino, (single) and a

resident of ____________________, Philippines, after having
been duly sworn to in accordance with law, hereby depose and
say:

That I am a holder of an ACKNOWLEDGEMENT RECEIPT

bearing No. _________________ with the principal amount of
__________ Pesos only (P45, 000.00) issued to me by the
______________, Tagum Branch, Tagum City, Davao del Norte;

That the said Acknowledgement Receipt was lost and can no

longer be found despite earnest efforts I have exerted to find the
same;

That I am executing this Affidavit to establish the fact of loss

and in connection with the requirement of the ____________
Tagum Branch, Tagum City, Davao del Norte, and for other legal
purposes this may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this

_____ day of _________ at Tagum City, Davao del Norte,
Philippines.

_________________
Affiant

SUBSCRIBED AND SWORN to before me this _____ day of

_________ at Tagum City, Davao del Norte, Philippines.Affiant
exhibited to me her (ID no.)_________ as proof of identity.

Doc. No. ______;

Page No. ______;
Book No. _______;
Series of 2022.