REPUBLIC OF THE PHILIPPINES)

CITY OF LAOAG ) S.S.

AFFIDAVIT OF LOSS
I, EVA G. MARTINEZ, of legal age, married, Filii!o Ci"i#e! a!d a re$ide!" of
Brg%. &', Sa! (o$e, )&* (. Ag+aoili S"., Laoag Ci"%, P,ilii!e$, af"er ,a-i!g .ee!
d/l% $0or! "o i! a++orda!+e 0i", la0, ,ere.% -ol/!"aril% deo$e a!d $"a"e1
That I am a holder of a Bureau of Internal Revenue (BIR) Card which
contains my Taxpayers Identification Number !"#$"%"$&%' issued by the BIR
(aoa) City*
That I always put the said BIR card in my closet inside my room to)ether
with other documents in my possession*
That when I was as+ed by the officers in the Bureau of Internal Revenue to
produce the said card the same was not in the aforementioned closet where I use
to +eep it*
That I exerted efforts to locate the same but to no avail*
That my BIR Card has never been confiscated nor apprehended for any
violation of the law* and
That I am executin) this affidavit to attest to the truth of the fore)oin) facts
and for whatever lawful purpose it may serve,
IN TRUTH WHEREOF, I ,a-e ,ere/!"o $e" m% ,a!d ",i$ &2
",
da% of (/l%
*'&* a" Laoag Ci"%, P,ilii!e$.
EVA G. MARTINEZ
Affia!"
Profe$$io!al Tea+,er I3 No. 4''5266&2
7alid /!"il1 '68'98*'&:
SUBSCRIBED AND SWORN "o .efore me ",i$ &2
",
da% of (/l% *'&* a" Laoag
Ci"%, P,ilii!e$. Affia!" e;,i.i"ed ,er roof of ide!"i"% i!di+a"ed .elo0 ,er !ame a!d
$ig!a"/re.