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SUBSCRIBED AND SWORN To Before Me A Notary Public For and in La Trinidad

Guillermo Challoy Agyapas purchased a flat screen TV from Tiongsan Supermart in September 2017 and was issued an official receipt, which he later destroyed by accidently washing it. He is now requesting a new official receipt be issued by the Land Transportation Office as the original was lost. He affirms the facts in this affidavit are true and accepts any liability from the reissuing of the receipt. The affidavit was sworn to on July 13, 2017 in La Trinidad, Benguet, Philippines.

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163 views2 pages

SUBSCRIBED AND SWORN To Before Me A Notary Public For and in La Trinidad

Guillermo Challoy Agyapas purchased a flat screen TV from Tiongsan Supermart in September 2017 and was issued an official receipt, which he later destroyed by accidently washing it. He is now requesting a new official receipt be issued by the Land Transportation Office as the original was lost. He affirms the facts in this affidavit are true and accepts any liability from the reissuing of the receipt. The affidavit was sworn to on July 13, 2017 in La Trinidad, Benguet, Philippines.

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black stalker
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© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Republic of the Philippines)

La Trinidad, Benguet) s.s


x- - - - - - - - - - - - - - - - -x
AFFIDAVIT OF LOSS

I, Guillermo Challoy Agyapas, of legal age, married, Filipino, and resident of


Bayabas, Pico, La Trinidad, Benguet, Philippines, after having been duly sworn to in
accordance with law, do hereby depose and state THAT:

1. I purchased from Tiongsan Supermart Incorporated (Tiongsan) located at Km.


4, Pico, La Trinidad, Benguet a flat screen television (TV) described as
Pensonic LED -1859 sometime on September 18, 2017. Accordingly, I was
issued an Official Receipt (OR) for the said purchase by Tiongsan. What I
recall is that I kept the said OR inside my sling bag at that time.

2. Thereafter, I brought home the said television. After few weeks of using the
same, I observed that the said TV experienced malfunction or unsatisfactory
performance. Therefore, I decided to refer the matter to Tiongsan, the
dealer/distributor. I was then required to present the Official Receipt thereof.

3. However, said Official Receipt had been dilapidated and destroyed when I
erroneously placed my pant containing the Official Receipt into the laundry
machine. Hence, said document is already rendered totally lost as it is already
beyond repair and recovery;

4. The said Official Receipt has not been confiscated by Government authorities
for violations of law nor surrendered to any private person or entity for the
enforcement of a civil obligations, but due solely to the foregoing reason;

5. I am executing this Affidavit to plead and request the office of the Land
Transportation Office (LTO) to issue me a new Driver’s License Official
Receipt in lieu of the one which was destroyed and lost. That, I hereby bind
myself to fully excuse the LTO for any liabilities either civil or criminal that it
may incur for the issuance of the requested Official Receipt;

6. Finally, I am executing this affidavit to attest to the truthfulness of the


foregoing facts and for all legal intents and purposes it may serve well.

IN WITNESS WHEREOF, I have hereunto set my hand this 13 th day of July


2017, at La Trinidad, Benguet, Philippines.

CRISANTO C. CAYABAS
Affiant
Senior Citizen’s ID No.: 2010-2632
Issued at: Itogon, Benguet
Issued on: April 1, 2013

SUBSCRIBED AND SWORN to before me a Notary Public for and in La Trinidad,


Benguet, Philippines this 13th day of July, 2017, by the above Affiant, who exhibited to me his
ID as competent evidence of identity with picture above his name and identified by me to be the
same person who personally signed before me the foregoing Affidavit.

ATTY. JOECLE R. DONGLA


Doc. No. 443 Notary Public,
Page No. 89 My commission expires on January 5, 2019
Book No. IV TIN No.431-403-131; Roll No. 60543, 3-23-2012
Series of 2017 PTR No. 5012179, January 5, 2017, Benguet;
IBP No. 1039762; December 13, 2016; Baguio-Benguet
S&B Bldg. FA 224, Km. 4, La Trinidad, Benguet

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