Republic of the Philippines)

Province of _______________) S.S

City of ________)

AFFIDAVIT

I, ________________, of legal age, Filipino, married and a resident of

_____________________________, after having been duly sworn to in
accordance with law, do hereby depose and state;

1. That I am the proprietor of ______________, registered last

___________________ with Certificate of Registration No.
______________;

2. That I want the aforesaid business to be closed

3. That I have NO CREDITORS or no outstanding and pending financial

obligations in connection with my business;

4. That I am executing this affidavit to attest to the veracity of the

foregoing facts and for any legal purpose this may serve thereby;

IN WITNESS WHEREOF, I have hereunto affixed my signature this

________________ at ____________________, Philippines.

___________________
AFFIANT

SUBSCRIBED AND SWORN TO before me this _______________ at

________________________, Philippines.

Doc. No. ____

Page No. ____
Book No. ____
Series of 2017