REPUBLIC OF THE PHILIPPINES)

LAS PIÑAS CITY )S.S.

AFFIDAVIT OF LOSS

I, , of legal age, Filipino, and with residence address at Rodriguez St., ,

after having been duly sworn to in accordance with law, hereby depose and say
that:

1.I am the subscriber of Manila Water Services for the water services at Gov.
E. Rodriguez St, Taguig City under Meter No. 15404910.

2. As such, a water meter was installed at the said water service address.

3. The said meter with meter no 0 was stolen.

4. Inspite of diligent efforts to look for said meter, all such efforts proved
futile and in vain up to this time, thus, I am declaring the loss of the said meter.

5. I am executing this affidavit to attest to the truth of the foregoing facts

and for all its legal intents, effects, consequences and purposes.

Affiant

SUBSCRIBED AND SWORN TO BEFORE ME, this October 8, 2013 at Las

Pinas City.

Doc. No. _____

Page No. ______
Book No. _____
Series of 2013.