Republic of the Philippines)

In the City of Baguio……….) S.S.

AFFIDAVIT OF LOSS
I, BENILDA A. BALANTAN, of legal age, married, Filipino Citizen, with
postal address at Ducot, Ucab, Itogon, Benguet, Philippines, after having been
duly sworn to in accordance with law hereby depose and state that:

1. I am an former proprietress of a certain business, Balantan’s Store,

located at Ducot, Ucab, Itogon, Benguet and which was duly
registered with the Bureau of Internal Revenue, hence, was issued a
ASK FOR RECEIPT NOTICE;

2. However, I could not remember anymore where I kept the said ASK
FOR RECEIPT NOTICE. I and my husband exerted diligent effort to
locate the said ASK FOR RECEIPT NOTICE in our house and in our
store but the same could no longer be found, hence, considered
forever lost;

3. Said ASK FOR RECEIPT NOTICE was never given nor pledged to
anyone for any purpose whatsoever, nor was it taken or confiscated
by the authorities for any violation of the business law;

4. I am executing this affidavit to attest to the veracity and truthfulness

of my foregoing statements and for other lawful intents and purposes
it may serve.

IN WITNESS HEREOF, I have hereunto affixed my signature this 19th

day of January, 2018 at Baguio City, Philippines.

BENILDA A. BALANTAN
AFFIANT
BIR TIN: 446-676-352-000
Date of Issue: 02-05-2014

SUBSCRIBED AND SWORN to before me this 19th day of January, 2018

at Baguio City, Philippines. Affiant personally appeared before me and
represented to me herself to be the same person who executed and signed this
instrument.

MODESTO T. ANDONG
Notary Public
Comm. No. 39-NC-18-R/Until: December 31, 2019
PTR No. 3397734/12-13-2017/BC
IBP No. 1083758/12-13-2017
Baguio-Benguet Chapter
Roll No. 31289/5-15-81/Manila
Doc. No. 090; MCLE COMPLIANCE No. VI-0000192/June 14, 2016
Page No. 19; BIR TIN No. 121-017-652
Book No. XXVIII; No. 19, 2nd Floor Old Market Bldg.,
Series of 2018. Magsaysay Ave., Baguio City, Philippines