REPUBLIC OF THE PHILIPPINES)

City of _______________________ ) S.S.

AFFIDAVIT OF LOSS

I, _____________________________(name of affiant), Filipino, of legal age,

________________ (civil status), and a resident of
____________________________________________________ (address), after
having been duly sworn to in accordance with law, do hereby depose and state:

1. That sometime in _______________, an Official Receipt (OR) was issued

in my favor by ______________________________ (establishment) as
evidence of my downpayment for the
______________________________________ (describe purpose of
payment) to be provided by the said establishment;

2. That I kept and filed the said OR together with other receipts of transactions
issued to me for some period in my files at home and place of work;

3. That as in the ordinary course of business, I thrash or tear and destroy

receipts of past transactions after some time;

4. That I have earnestly and diligently exerted effort to search and locate for
the aforesaid OR;

5. That notwithstanding such earnest and diligent effort to find and locate the
aforementioned OR, the same cannot be found nor located and is now
therefore deemed as lost or destroyed inadvertently;

6. That I execute this affidavit to attest to the truth of all the foregoing facts
and incidents.

Affiant further sayeth naught.

IN WITNESS WHEREOF, I have hereunto set my hand this ____ day of

________________ 2022, in ____________ City.

(. Printed name and signature .)

Affiant

SUBSCRIBED AND SWORN to before this ____ day of __________ 2022 in

_____________ City.

NOTARY PUBLIC

Doc. No. ______;

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