REPUBLIC OF THE PHILIPPINES)

________________ City……………..) S.S.

AFFIDAVIT OF LOSS

I, ___________________, Filipino, of legal age, single, and a resident of P-15,

Brgy. San Juan,, ___________, after having been sworn in accordance with law
hereby depose and state that:

1. I am a loyal client of GAS GAS GAS , thus, I was qualified to join in

the promo called MOTORCYCLE BLUNANZA. Thereafter, I was
issued raffle tickets for the said promo and was given the claim stub
(portion of the said ticket). Among raffle tickets issued to me is ticket
no. 00000000000

2. Recently, I was informed by staff of GAS GAS GAS that I was

among the lucky winners of the MOTORCYCLE BLUNANZA and
my raffle ticket no. 000000000000 won P100000.00 cash prize.

3. Upon learning the said good news, I immediately tried to retrieve

the claim stub of the said winning raffle coupon which was place
inside my wallet. I was so surprised to find out that the said claim
stub (portion of the said ticket) was missing.

4. Efforts were exerted to locate the said winning claim stub, but in
spite of diligent search, it could not be found and the same is now
beyond recovery.

5. As such, I am executing this Affidavit of Loss to attest to the truth of

the foregoing and to allow me to claim the said prize from GAS GAS
GAS.

IN WITNESS WHEREOF, I have hereunto set my hand this 10 th day June

2019 in the City of _______________ Philippines.

_______________________________
Affiant

SUBSCRIBED AND SWORN to before me, this 10th day of June, 2019 in
_____________ City.

Doc. No. : ________;

Page No. : ________;
Book No. : ________;
Series of 2019.