Republic of the Philippines )

Province of Tarlac ) s.s

x---------------------x

AFFIDAVIT OF LOSS
I, JOCELYN SERNA, Filipino, of legal age and a presently residing at Phase 2,
Camella Homes, Tarlac City, after having been duly sworn to in accordance with law,
hereby depose and state, that:

1. Because of the construction at my house at Camella Homes, I furnished a

construction bond amounting to T

HIRTY THOUSAND PESOS (P30,000.00);

2. Said bond are evidenced by official receipts bearing the numbers: 0014566 and
0014567;

3. I was keeping the said receipts in my residence mentioned above;

4. Recently, while I was preparing my documents for the release of the said bonds,
I discovered that the original copies of the said receipts are missing. I exerted
reasonable effort to locate the receipts, but to no avail, and I am now considering
said receipts as lost and beyond recovery;

5. I am executing this instrument to attest the foregoing and for other legal intent
and purpose.

END OF AFFIDAVIT.

IN WITNESS WHEREOF, I hereby affix my signature this __________ in __________.

JOCELYN SERNA
Affiant
I.D. __________________
______________________

SUBSCRIBED AND SWORN to before me this ___________ in ____________ affiant

personally appeared exhibiting her competent evidence of identity provided above.

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 2018