REPUBLIC OF THE PHILIPPINES

)
CITY OF DIPOLOG ) S.S.
x--------------------------------------x

AFFIDAVIT OF LOSS

KNOW ALL MEN BY THESE PRESENTS:

I, CHONA MAUNES PANDONG of legal age, Filipino, married, and a
resident of Upper Turno, Dipolog City , after having been sworn in accordance with
law, hereby deposes and states the following:

1. I am a holder and possessor of an original copy of Certificate Authorizing
Registration (CAR) no. CAR2013 00449201 from the office of the Bureau of
Internal Affairs (BIR), Dipolog City;

2. I have recently discovered the said item is irretrievably lost and can no longer
be found despite diligent efforts to locate the same;

3. I execute this affidavit to attest to the truth of the foregoing and to request the
same original copy of Certificate Authorizing Registration (CAR) no.
CAR2013 00449201 from the said office.

Signed on the date and at the place indicated below.

CHONA MAUNES PANDONG
Affiant
TIN no: 417-130-091
Issued in Dipolog City

SUBSCRIBED and SWORN TO before me on the date and at the place indicated below.

The affiant exhibited to me her competent evidence of identity as indicated above.
Signed this ______________at ________________, Philippines.

WITNESS MY HAND AND SEAL.

Notary Public

Doc. No.___
Page No.___
Book No.___
Series of 2017.

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