REPUBLIC OF THE PHILIPPINES)

CITY OF DIPOLOG ) s.s.

AFFIDAVIT OF LOSS

I, RUEL TIZON COLUMNAS Filipino, married, of legal, age and with postal address
at Baybay Galas, Dipolog City after having been subscribed under the Law, do hereby
depose and state that:

1. Sometime February 4, 2019 , I purchased a SAMSUNG LED TV, 43 inches at

SOLIDMARK, located at Quezon Avenue,Miputak, Dipolog City, more
particularly described as follows:

MODEL NO.18330-UA43N5003 SERIAL NO.

BRAND NAME: SAMSUNG

for which I was issued an OFFICIAL RECEIPT (OR);

2. Unfortunately, while I was searching for the said OFFICIAL RECEIPT (OR) at
my residence, I discovered that the same was already lost/missing.

3. Despite deliberate my effort to recover the said Receipt OFFICIAL RECEIPT

(OR), all my efforts proved futile since the same was no where to be found and
should therefore be considered lost.

I am executing this affidavit to attest to the truth of the foregoing and for what ever
legal purpose this may serve.

IN WITNESS WHEREOF, I have hereunto affix my signature on this __________at

the City of Dipolog.

RUEL TIZON COLUMNAS

Affiant
JO1-02-037767

SUBSCRIBED AND SWORN to before me this _________ day of 2019, at the

City of Dipolog.

Doc. No: ______

Page No: ______
Book No: _____
Series of 2019