Republic of the Philippines )

City of Dipolog ) S.S

x------------------------------------x

AFFIDAVIT OF LOSS

I, CARL MIRANDA SALAZAR, Filipino, of legal age, and a resident of Turno, Dipolog
City, after having duly sworn in accordance with law, do hereby depose and state that:

1. That I am the holder of receipt no. 0711-2019-00543 issued by M Lhuillier Gen.

Luna St., Dipolog City Branch ;

2. That sometime on October 2019, I discovered that my M Lhuillier Receipt was

probably lost or misplaced;

3. Despite diligent search and efforts to locate the said RECEIPT, I could not find the
same such that I now believe that it is now lost beyond recovery;

4. As such that I am executing this affidavit of loss to attest to the truth of the
foregoing and to support the application for the issuance of new one in lieu of
the one which was lost.

IN WITNESS WHEREOF, I have hereunto affixed our hands this_____day of

_______________ at Dipolog City, Philippines.

CARL MIRANDA SALAZAR

Affiant

SUBSCRIBE AND SWORN TO before me this ______________ at Dipolog City,

Philippines, with affiant exhibiting his STUDENT ID No. 140435.

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Series of 2019
Republic of the Philippines )
City of Dipolog ) S.S
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AFFIDAVIT OF LOSS

I, FREDERICK S. CALOG, of legal age, Filipino, married and a resident of

Barangay Alvinda, Mutia, Zamboanga del Norte, after having duly sworn in accordance with
law, do hereby depose and state that:

1. That I am a holder of an Official Receipt from a purchase of a chainsaw in

Oroquieta City in the year 2017 which is more particularly described as follows:
BRAND SERIAL MACHINE NO.

ZERO70 STEEL S178200084

2. That the said document while in my possession was misplaced and could no
longer ne located inspite of exerting efforts of locating them;

3. That I am executing this affidavit to attest the truth of the foregoing and for
whatever legal purpose it may serve.

AFFIANT FURTHER SAYETH NAUGHT.

IN WITNESS WHEREOF, we have hereunto affixed our hands this____ day of

_______________ at ________________.

FREDERICK S. CALOG
Affiant
Philhealth ID 16-050166521-2

SUBSCRIBE AND SWORN TO before me this August 31, 2018 at Dipolog City.

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Series of 2018.