REPUBLIC OF THE PHILIPPINES)

CITY OF TAGBILARAN) S.S.

AFFIDAVIT OF LOSS

I, NOEL MAKABAYAN, Filipino, of legal age, married and resident of Mabini,

Bohol, Philippines, after having been duly sworn to in accordance with law, do hereby
depose and say:

1. That I am the holder of the customer’s copy of the OFFICIAL RECEIPT of

__________ Printer (L9U63A), with invoice no. 113738 and Transaction No. 58455,
purchased ________;

2. That sometime __________, the above-mentioned customer’s copy of the

OFFICIAL RECEIPT somehow got lost and despite painstaking efforts to locate it, the
same could nowhere be found;

3. That said customer’s copy of the OFFICIAL RECEIPT is not in the hands of
any third person or authority for value or consideration for any purpose whatsoever, nor
was it confiscated for any legal cause;

4. That I am executing this affidavit to attest to the fact of loss of the above-
mentioned customer’s copy of the OFFICIAL RECEIPT and for whatever other legal
purposes this may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this 26th day of

February 2018, in Tagbilaran City, Bohol, Philippines.

Affiant

SUBSCRIBED AND SWORN to before me this 26th day of February 2018 in

Tagbilaran City, Bohol, Philippines.