REPUBLIC OF THE PHILIPPINES)

CITY OF GENERAL SANTOS…….) S.S.

X-----------------------------------X

AFFIDAVIT OF LOSS

I, ALI FRANCIS ROYECA SERQUIÑA, Filipino, of legal age, and a resident of #61 NLSA
Road, General Santos City, after being duly sworn to in accordance with law, hereby depose
and say:

1. That I have the custody of counter receipt issued by KCC Mall of Gensan,
located in J. Catolico St., General Santos City, issued to various customers,
with the following details:
Charged to: Sales Invoice Date Amount
KCC MALL OF GENSAN 024535 20 June 2022 Php 353,333.44
KCC MALL OF GENSAN 024534 20 June 2022 Php 114,505.87

2. That I had the said counter receipt placed inside an envelope for safe-keeping
and easy reference;
3. Lately, when I tried to retrieve the said counter receipt from its envelope with
the above-mentioned counter receipts were already lost and could no longer
be found;
4. That I execute this affidavit to attest to the truth of the foregoing for all legal
purposes.

AFFIANT FURTHER SAYETH NAUGHT.

IN WITNESS WHEREOF, I have hereunto set my hand this February 23, 2023, in
General Santos City, Philippines.

_____________________________
ALI FRANCIS ROYECA SERQUIÑA
Affiant

SUBSCRIBED AND SWORN TO before me this February 23, 2023, in General Santos City
by affiant who exhibited to me his valid i.d.: _________________.

Doc. No. 476;

Page No. 96;
Book No. 212;
Series of 2023.