REPUBLIC OF THE PHILIPPINES.

)
PROVINCE OF SAMAR……………) SS.
CITY OF CATBALOGAN………..… )

AFFIDAVIT OF LOSS

I, DIXTER EDIESON L. BASIERTO, of legal age, single, Filipino and with present
address at Brgy. Catalina, Jiabong, Samar, after having been duly sworn to in accordance with
law do hereby depose and state that:

1. I am pharmacist at South Star Drug, Inc. Catbalogan Branch located at Del

Rosario St., Catbalogan City, Samar; as such a company E-pass was issued in
my favor;

2. Unfortunately, however, on 15 August 2022, while I was on my way back

home, I did not notice said company E-pass dropped from my bag and I
discovered such loss only upon reaching home, I exerted efforts to locate said
company E-pass but to no avail, such that I now consider it lost for all intents
and purposes;

3. The loss of said company E-pass is made in good faith and never intended to
defraud the government, particularly, the South Star Drug, Inc. and third
persons and I hold the said agencies free from any liabilities or obligations
arising from such loss;

4. I am executing this statement to attest the truth of all the foregoing, and to
secure a new company E-pass in lieu of the lost one and for other legal
purposes.

IN WITNESS WHEREOF, I hereunto affix my signature this 08 th day September 2022 at

Catbalogan City.

DIXTER EDIESON L. BASIERTO

Affiant

SUBSCRIBED AND SWORN to before me this 08th day September 2022 at Catbalogan
City, Samar, affiant exhibiting to me his PRC ID No 0084142, issued on March 25, 2019, valid
until November 02 2022.

Doc No. _______;

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