REPUBLIC OF THE PHILIPPINES )

Province of Negros Oriental )

City of Dumaguete )S.S.
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AFFIDAVIT OF LOSS

I, JOSIE CABALLERO, Filipino, of legal age, single, and a resident of Valencia,

Negros Oriental, Philippines, after being duly sworn in accordance with law, depose and
state:

1. That I am the sole proprietor of Unicorn Diving Services, Hostel and Restaurant
located at Poblacion, Dauin, Negros Oriental;

2. That the said business had been duly registered with the Bureau of Internal Revenue
last July 18, 2016;

3. That subsequently, the said business have printed 12 booklets of receipts numbered
from 0001-0600;

4. That sometime around the early quarter of 2017, I discovered that my receipts with
booklets number 7-11 were missing;

5. That despite diligent search and efforts to locate the above mentioned receipts, I could
not find the same such that I now believe that they are now lost beyond recovery;

6. As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
facts and for the closure of my business before the BIR.

IN WITNESS WHEREOF, I have hereunto set my hand this __________________

at Dumaguete City, Philippines.

JOSIE CABALLERO
Affiant

SUBSCRIBED AND SWORN to before me, this _________________ in the City of

Dumaguete, affiant exhibiting before me as competent proof of his identity her TIN 487-
349-657-000.

Doc. No. ______;

Page No. ______;
Book No. ______;
Series of 2018.