REPUBLIC OF THE PHILIPPINES)

CITY OF ILOILO………………...) S.S.

AFFIDAVIT OF LOSS

I, JESSIETE A. AMERILA, Filipino, of legal age, single, with residence and postal address at
138 Rizal Street, Brgy. San Jose, Arevalo, Iloilo City, Iloilo, after having been sworn to in accordance
with law, hereby depose and state:

1. That on October 07, 2018, I sent a principal amount of PHP 1,000.00 to Nestor Jetano
through Palawan Express Pera Padala;

2. That following the aforementioned event, I lost my Palawan Express Pera Padala receipt
with transaction code AEW-13-23745-ZAW;

3. That despite diligent and religious effort to locate its whereabouts, the same cannot be
located and nowhere to be found and my effort were proven futile;

4. That I am executing this affidavit for purposes of apprising the office concerned regarding
the loss and replacement of the aforementioned receipt. And to apprise the authorities
concerned on the veracity of the foregoing facts and circumstances and for whatever legal
purposes this may serve.

FURTHER AFFIANT SAYETH NAUGHT.

________________________________________
JESSIETE A. AMERILA
Affiant

CTC No. : 12579330

_______________________
Issued On : SEPTEMBER 24, 2018
_______________________
Issued At : ILOILO CITY
_______________________

SUBSCRIBED AND SWORN to before me this 30th October, 2018 at Iloilo City, Philippines,
affiant exhibited to me his Community Tax Certificate abovementioned.

Doc. No. _______________;

Page No. _______________;
Book No. _______________;
Series of 2018