REPUBLIC OF THE PHILIPPINES )

Province of Isabela ) S.S.

Municipality of Angadanan )
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AFFIDAVIT OF LOSS

I, ____________________, Filipino, of legal age, and a resident of _______________,

Angadanan, Isabela, after being duly sworn to in accordance with law, hereby depose and state:

That I am the same person executing this affidavit;

That on September 2016, I bought a 32 Samsung television set at the SM Appliances at

Cauayan City, Isabela and was issued the corresponding receipt;

That I placed the said official receipt on a cabinet in our house;

That recently, I searched for the said official receipt but the same was already missing;

That despite diligent search and effort to locate it, the same could no longer be found
such that it is already considered lost beyond recovery;

As such, I am executing this Affidavit to attest to the truth of the foregoing and for
whatever legal purpose it may serve.

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

Angadanan, Isabela.

_______________________________
Affiant
ID No. ____________________

SUBSCRIBED AND SWORN to before me, this ______________ at Angadanan, Isabela

whom I have identified through competent evidence of identity.