AFFIDAVIT OF LOSS

KNOW ALL MEN BY THESE PRESENTS:

That I, ______________-, Filipino, of legal age, with residence and postal address
at ____________, Laguna, after having been duly sworn to in accordance with law, do
hereby depose and state;

1. That issued in my favor by the Bureau of Internal Revenue is a Tax

Identification Number (TIN) Identification Card;

2. That I usually keep the said TIN ID inside my wallet together with my other
ID’s;

3. That sometime in December of 2015, when I arrived after having paid for
an LBC shipment, I searched for my TIN ID inside my wallet, however, I
found out that my TIN ID was already nowhere to be found;

4. That I exerted all efforts to find the TIN ID, however, the search remained
futile, and my TIN ID is deemed beyond recovery;

5. That I am executing this affidavit to attest to the truth of the foregoing and
to apply for the replacement of my TIN ID, and for whatever legal purposes
it may serve;

Further, affiant sayeth naught.

_______________
Affiant

SUBCRIBED AND SWORN TO BEFORE ME, this _____ day of ________ 2016,
affiant presenting to me her valid Senior Citizens’ ID with photograph and specimen
signature. With ID Number __________ issued on _______________. That the foregoing
affidavit was freely and voluntarily issued by affiant.

NOTARY PUBLIC

Doc No. ______;

Page No. ______;
Book No. ______;
Series of 2016.