REPUBLIC OF THE PHILIPPINES )

_________________________ City, )

AFFIDAVIT OF LOSS

I, DUNGCA, REBECCA y DELA CRUZ Filipino, of legal age, single and with
business address at 64 D. Mangubat St.,Zone 3, Dasmarinas, Cavite, after having duly
sworn according to law , depose and state THAT :

1. I am the owner of BI-SY EAT RESTAURANT with the same business address
stated above and TIN No. of 217-840-804-001 ;

2. I have a Printer’s Certificate of Deliver of Receipts/Invoices from El Marysh

Printing & General Merchandise SN 0001 to 1250 on June 07, 2004 with
Printer’s Accreditation No. OCN 1AU00000240689 together with Authority To
Print and attached Tax Payer-user’s Sworn Statement ;

3. Sometimes in April 2013 when I tried to retrieve the original copies of the
above mentioned certificate together with authority to print and attached Tax
Payer-user’s Sworn Statement for proper filing with other BIR records and
safekeeping purposes, the same could no longer be located ;

4. Despite of diligent efforts exerted, I could no longer locate, find or recover the
said Authority To Print , Printer’s Certificate of Deliver together with attached
Tax Payer-user’s Sworn Statement , and to the best of my knowledge, the same
are truly lost ;

5. The said Authority To Print, Printer’s Certificate of Deliver of Receipts/Invoices

together with Tax Payer-user’s Sworn Statement are never confiscated by any
officer of the law or the issuing office or agency due to the violation of any law,
statute , order, rule or regulation;

6. This affidavit is being executed in order to establish all the facts herein above
narrated for the information and guidance of the authority concerned ; to attest to
the truth and veracity of the foregoing, to request for a replacement of the said
from respective government agencies as may be applicable and for whatever legal
purpose the same it may serve .

IN WITNESS WHEREOF, I have hereunto affixed my signatures this 27 th day of

April 2015 in Dasmarinas City.

REBECCA DELA CRUZ DUNGCA

Affiant
TIN 217 -840-804-001

SUBSCRIBED AND SWORN to before me this 27 th day of April 2015 in

Dasmarinas City exhibited to me his valid TIN / Voter’s ID ( see attached xerox copy)

NOTARY PUBLIC
Doc. No. ________
Page No ________
Book No. ________
Series of 2015 _____