REPUBLIC OF THE PHILIPPINES )

________________________________ ) S.S.

AFFIDAVIT OF LOSS

I, _______________________, Filipino, of legal age, single and with residence

at ___________________________________________________, after having been duly sworn
in accordance with law, do hereby depose and state THAT:

1. I am the owner of _________________________________, a business duly organized

and existing under and by virtue of the laws of the Republic of the Philippines;

2. ___________________________ was registered with

_____________________________ under _______________________________ and
was issued a CERTIFICATE OF BUSINESS CLEARANCE;

3. Sometime in_______________________, the original copy of the said CERTIFICATE

OF BUSINESS CLEARANCE could not be found and that despite diligent search and
efforts, the same could no longer be found, such that I believe it is now lost beyond
recovery;

4. 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 ____ day of ________, 2019
in ___________________________.

Name of Affiant
Affiant
CTC No: ______________
Issued on: _____________
At: ___________________

ACKNOWLEDGEMENT
SUBSCRIBED AND SWORN to before me, this _____ day of ______________, 2019 in
___________________________, with affiant exhibiting his ___________________________,
issued on ___________________________ at ___________________________.

Notary Public

Doc. No. : ________;

Page No. : ________;
Book No. : ________;
Series of 2019.