REPUBLIC OF THE PHILIPPINES )

Province of Leyte ) S.S.

Municipality of Villaba )
x-------------------------x

AFFIDAVIT OF LOSS
I, ROGELIO J. BAAY, Filipino, of legal age, married and a resident of Brgy. Poblacion
Del Norte, Villaba, Leyte, Philippines, after having been duly sworn to in accordance with law, do
hereby depose and state:

1. That I am an incumbent member of the Sangguniang Bayan of the Municipality of

Villaba, Province of Leyte, Philippines;

2. That on August 15-18, 2016, I, together with the other members of the Sangguinang
Bayan of Villaba, went to Puerto Princesa City, Palawan, to attend a seminar on
Sangguniang Rules of Procedures and Dual Functions in Local Legislation;

3. That sometime on August 20, 2016, when I was preparing all my tickets and official
receipts for liquidation, I discovered that my Supercat ticket (as described below) got
lost;

SUPERCAT TICKET
From Cebu to Ormoc
Name: Rogelio J. Baay
Date: 08/19/2016
Voyage No. 55H/2016-695
Amount: ₱585
Issued by: CEBAGGJR/CEBP4
Remarks: VAT EXEMPT/SENIOR CITIZEN

4. That despite diligent search and efforts to locate said Supercat ticket, I could not find
it such that I now believe that it is now lost beyond recovery;

5. As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
and to support the liquidation of my expenses of the said official trip to Palawan and
for whatever legal purpose/s that it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this 30th day of June, 2017 at
Villaba, Leyte, Philippines.

ROGELIO J. BAAY
AFFIANT

SUBSCRIBED AND SWORN to before me, this 30th day of June, 2017, by the Affiant who
is personally known to me (or whom I have identified through competent evidence of identity) and
who exhibited his OSCA ID No. 123 issued on 12/15/05 at Villaba, Leyte, Philippines.

NOTARY PUBLIC
Doc. No. ______;
Page No. ______;
Book No.______;
Series of 2017.