REPUBLIC OF THE PHILIPPINES)

CITY OF QUEZON

) S.S.

AFFIDAVIT OF LOSS

I, Isaiah Paul G. Sacramento, Filipino, of legal age, single, and a resident of 71-I M. H. Del Pilar St.,
Brgy. San Antonio, Quezon City, after having duly sworn to in accordance with law do hereby depose
and state that:
1. I am a holder of an Official Receipt (OR) for the purchase of a Sony Bravia LED Television,
issued by SM Appliance Center, on March 2015, at SM City San Lazaro, Manila;
2. Sometime in April 8, 2016, I lost the above Official Receipt under the following circumstances:
I and my family moved in from our former address: 2548-B Rizal Ave. Sta. Cruz, Manila to our
current address: 71-I M. H. Del Pilar St., Brgy. San Antonio, Quezon City;
3. Despite diligent efforts exerted, I could no longer locate, find or recover the said Official Receipt,
and to the best of my knowledge, the same is truly lost;
4. I am executing this affidavit to attest the truth of the above statement of facts and to request for a
Certification of Purchase of the item stated above from SM Appliance Center, for the purpose of
warranty verification of the said item;
IN WITNESS WHEREOF, I have hereunto set my hands this 7th day of October, 2016, at Quezon
City, Metro Manila.

ISAIAH PAUL G. SACRAMENTO

Affiant

SUBSCRIBED AND SWORN to before me this ____ day of October, 2016 here at ___________
_______________________________.

Doc No. ________;

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