Affidavit of Loss Receipts

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Republic of the Philippines)

)S.S.

AFFIDAVIT OF LOSS
OF RECEIPTS

I, EDITH CRUZ Filipino, of legal age, married, and a resident of


Rodriguez, Rizal, after having been sworn in accordance with law, hereby
depose and state that:

1. I am an Administrative Officer;

2. I have recently discovered that Provisional Receipt No. 785 dated


February 17, 2016 and Official Receipt No. 785 dated February 17,
2016 are now lost and beyond recovery, despite diligent efforts to
locate the same;

3. I am executing this Affidavit to attest to the truth of the foregoing, and


for whatever legal purpose this may serve.

IN WITNESS WHEREOF, I have hereunto affixed my signature on this _____


day of July, 2019 in ____________, Philippines.

EDITH CRUZ
Affiant

SUBSCRIBED and SWORN TO before me, a Notary Public in and for


______________ this ____ day of July, 2019, affiant exhibiting to me her
Philippine Passport No. _________________ which expires on ____________, as
competent evidence of identity.

Notary Public

Doc No. ______;


Page No. _____;
Book No. _____;
Series of 2019

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