Republic of the Philippines)

Province of Agusan del Norte) S.S.

City of Butuan)
x-------------x

AFFIDAVIT OF LOSS

I, CODERA SALVADOR Jr., Filipino, of legal age, married, and a resident

of San Vicente, Butuan City, after being duly sworn in accordance with law, depose
and state THAT:

The official receipts issued are particularly described as follows:

O.R. # DATE AMOUNT

June 10, 1997 November 12 to December 12, 1996 P 12, 530.00
December 12 to January 12, 1997 P 12, 460.00
January 12 to February 12, 1997 P 12, 390.00
5813890–0 February 12 to March 12, 1997 P 12, 360.00
March 12 to April 12, 1997 P 12, 250.00
April 12 to May 12, 1997 P 12, 180.00
5813891–0 May 12 to June 1997 P 12, 110.00
142438 July 1997 to October 1997 P 11, 830.00
1290421–0 November 1997 to October 1998 (2/6/01) P 10, 990.00
0193682 November 1998 to June 2003 P 7, 670.00
July 2003 to December 2003 P 6, 600.00
June 2004 to December 2004 P5, 810.00
January 05 to December 2005 P 4, 970.00

To my surprise, I discovered that the official receipts could no longer be

found;

As all efforts to find the same proved unrewarding, it is now safe to conclude
that recovery of the same is impossibility;

Thus, I execute this affidavit to establish its loss and for whatever purpose
that this may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this 26th day of May
2014 at Butuan City, Philippines.

CODERA SALVADOR Jr.

SUBSCRIBED AND SWORN TO BEFORE ME, a notary public in and for

Butuan City this 26th day of May 2014. Affiant personally came and appeared with
his , appeared and known to me as the same person
who personally signed the foregoing instrument before me and avowed under
penalty of law to the whole truth of the contents of said instrument.

Doc. No. ____;

Page No. ____;
Book No. ____;
Series of 2014.