REPUBLIC OF THE PHILIPPINES)

Legazpi City
) ss.
x-------------------x

A ffi d a v i t o f L o s s
I, , Filipino, of legal age, married and a resident of Unit 1 Homelots Ave., Dona
Maria Tagas, Daraga Albay Philippines, after having duly sworn in accordance with
the law, hereby depose and say;
1. That I am an employee of with the position of Medical
Representative;
2. That sometime on April 23, 2015 and April 28, 2015, I purchased
from the following establishments and was thereafter issued a
receipt for the cor responding purchased amount:
I. WAWAYS RESTAURANT
II. UNCLE TONS

Php 1,000.00
Php 375.00

2. That sometime on April 30, 2015 the said receipts was lost
and/or misplaced without fault or carelessness on my part;
3. That despite diligent search and eff ort the said receipts can no
longer be found and it is considered lost for all legal purposes; and
4. That I am executing this affi davit to attest the truth of the
foregoing statements and for the purpose of complying with the
requirements for liquidation of the April 2015 budget and for
whatever legal intent and purposes this may ser ve.

IN WITNESS WHEREOF, I have hereunto set my hand this 25 th day of

June 2015 in the City of Legazpi, Philippines.

Affiant
LTO Drivers License: N01-12-016215

SUBSCRIBED AND SWORN TO before me this 25 t h day of June

2015 at Legazpi City. Affi ant personally appeared.
Affi ant further
exhibited to me to his competent proof of identity through the document
written below his name, pursuant to Rule 2, Sec. 12 (a) of the 2004 Rules
on Notarial Practice.

Doc. No. ____;

Page No. ____;
Book No. ____;
Series of 2015.