Republic of the Philippines)

Province of Aklan ) S.S.

x-----------------------------x

AFFIDAVIT OF LOSS
I, _______________, of legal age, married and a resident of 745
Rizal St., New Washington, Aklan after having been duly sworn in
accordance with law do hereby depose and state:

That I am the Owner of __________________ located at

Barangay Cawayan, New Washington, Aklan, Philippines;

That the above-mentioned business is the holder of Taxpayer’s

Identification Number (TIN) ______________________, and
was issued by the Bureau of Internal Revenue an Official Receipt Booklet
No. 8 with Series Number ____________;

That said Official Receipt Booklet No. 8 with Series Number

________ was in my possession from the time of issuance but sometime
on the month of December of 2017, when I was checking and organizing my
documents, the said Official Receipt Booklet No. 8 with Series Number
__________ could no longer be located and was missing from the usual
place it was being kept;

Diligent efforts were made to recover the same, but said efforts
proved futile and in vain, so I considered it lost.

That said Official Receipt Booklet No. 8 with Series Number

_________ was not confiscated from me by any competent authority nor
delivered to any person to secure any obligations

As such, I am executing this Affidavit of Loss to attest to the truth of

the foregoing and for whatever legal purposes that this may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this June 25,

2018 at Kalibo, Aklan, Philippines.

_____________
Affiant

SUBSCRIBED AND SWORN to before me this June 25, 2018 at

Kalibo, Aklan, Philippines by ____________________, who has
satisfactorily proven to me his identity through his Drivers’ License No.
__________________________, for his identity, known to me to be
the same person who personally signed before me the foregoing Affidavit
and acknowledged that he executed the same.

Doc. No. 485;

Page No. 98;
Book No. V;
Series of 2018.