REPUBLIC OF THE PHILIPPINES)

________________________ )S.S.

AFFIDAVIT

I, ROXANNE D. PUA, of legal age, Filipino citizen, and with residence

address at Brgy. Antonino, Alicia, Isabela, after having been duly sworn in
accordance with law, state that:

1. I am the person executing this Affidavit;

2. On December 24, 2018 at around 6:30 in the evening, a fire broke

out at the premises of my Ricemill located at Brgy. Antonino,
Alicia, Isabela;

3. During the fire incident the following properties described as

follows were burned:

15 box 2.0mm THHN CU. Wire ₱ 27,150.00

1 box 3.5mm THHN CU. Wire 2,850.00
2 box 5.5.mm THHN CU. Wire 9,200.00
1200 mtrs 38mm THHN CU. Wire 210,000.00
4200 mtrs 100mm THHN CU. Wire 1,155,000.00
150 mtrs 250mm THHN CU. Wire 132,750.00
1 roll 3C-2.0mm THHN CU. Wire @500m 15,000.00
10.5 roll 3C-2.5mm THHN CU. Wire @500m 189,000.00
1 roll 3C-5.5mm THHN CU. Wire @500m 22,000.00
31 roll 3C-8.0mm THHN CU. Wire @300m 434,000.00
2 roll 3C-14.0mm THHN CU. Wire @100m 24,000.00
1 lot Cabinet type Panel Board w/ Breakers,Relay & Push Button 250,000.00
2 sets AVR 5kva 30,000.00
2 lots 100A Fuse Box 5,000.00
2 sets 1,500A Main Distribution Panel 100,000.00
50 pcs Electrical tape big 1,750.00
10 rolls Rubber Tape 750.00
50 pcs Angle Bar for Cable tray 11,750.00
15 kls Welding Rod 900.00
10 rolls 1/2"Ǿ Moldiflex 6,000.00
5 sets 3Ǿ Secondary Rock w/ Spool 5,250.00
20 pcs Receptacle 4x4 500.00
180 sets 40W Flourescent lamp w/ plate 324,000.00
25 sets 3gang Switch w/tape 3,125.00
15 sets 2gang outlet 1,425.00
40 pcs Utility box metal 1,000.00
Total ₱ 2,962,400.00
 4. I am executing this Affidavit to attest to the correctness and
truthfulness of the foregoing, and for whatever legal purpose it
may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this 29th day of

December in Santiago City.

ROXANNE D. PUA
Affiant

SUBSCRIBED AND SWORN to before me this 29th day of December in

Santiago City.

Doc. No. 229;

Page No. 46;
Book No. 23;
Series of 2018.