REPUBLIC OF THE PHILIPPINES)

CITY OF ILOILO) ss.

AFFIDAVIT

RE: TERMINATION OF BUSINESS

I, CHENE J. SEGURA, of legal age, married and a resident of Anilao, Iloilo, after having been duly
sworn in accordance with law do hereby depose and state:

That I am the owner of the business name KARERA AGRI MACHINERIES which is registered
with the Bureau of Internal Revenue (BIR);

That I am applying for the termination of the business, KARERA AGRI MACHINERIES,
registered with the BIR in ________________, with Certificate of Registration OCN No. __________,
which I decided to close effective __________________.

That the reason for the termination is due to lack of financial resources ;

That the business has no outstanding liability and obligation;

That I am executing this affidavit to attest to the truth of all the foregoing statements and for whatever
legal purpose it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this February 7, 2019 at Iloilo City, Philippines.

CHENE J. SEGURA
Affiant
PhilHealth ID No.: ______________
Issued on: _____________
At: ___________________

SUBSCRIBED AND SWORN to before me this February 7, 2019 at Iloilo City, Philippines.

Doc. No. : ________;

Page No. : ________;

Book No. : ________;

Series of 2019.