AFFIDAVIT OF LOSS

I, ________________, of legal age, Filipino, single, and resident of ____________________ after being
duly sworn according to law, hereby depose and state that:

1. I am the owner of __________________.

2. Sometime on July 27, 2022; Our delivery personnel lost the Counter Receipt issued to
__________________ with Delivery Receipt Number 015154 under the following circumstances:
DR No. -
Amount -
Returns -
Total 68,033

3. Despite diligent efforts exerted, we could no longer locate, find, or recover the said
Counter Receipt, and to the best of my knowledge, the same is truly lost.

4. The said Counter Receipt has not yet been collected by ______________ to ________________

5. In the event that the lost Counter Receipt should hereafter be found or located, I undertake to
forward or surrender the same to _____________________ for appropriate filing of documents.

6. I am executing this Affidavit to attest to the truth of the foregoing statements.

. AFFIANT FURTHER SAYETH NAUGHT.

IN WITNESS WHEREOF, I have hereunto set my hand this ____________________ at

_________________________.

________________________
Affiant

SUBSCRIBED AND SWORN to before me this ____________________, affiant exhibited to me his/her Competent
Evidence of Identity by way of __________________ issued at ______________ on __________________.

Doc. No. ______;

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