REPUBLIC OF THE PHILIPPINES )

_________________________ City, )

AFFIDAVIT OF LOSS

I, ADEODATO LOGROÑO JR. MICABALO, Filipino, of legal age, married

and with business address at 1712 F. Agoncillo St., Brgy. 694, Malate, Manila, after
having duly sworn according to law , depose and state THAT :

1. I am the owner of A.M.L. TRUCKING with the same business address stated
above and TIN No. of 209-608-788-000 ;

2. I executed a Tax Payer-user’s Sworn Statement attached to Printer’s Certificate of

Deliver of Receipts/Invoices issued by Fernandez, Hilario De Guzman in
November 2013 with Printer’s Accreditation No.003804 ;

3. Sometimes in December 2013 when we tried to retrieve the original copy of Tax
Payer-user’s Sworn Statement attached to Printer’s Certificate of Deliver of
Receipts/Invoices for proper filing together with other BIR records and for
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 Tax Payer-user’s Sworn Statement , and to the best of my knowledge, the
same is truly lost ;

5. The said Tax Payer-user’s Sworn Statement is 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 2 nd day of

September 2014 in ____________________ City.

ADEODATO M. LOGRONO JR.

Affiant
TIN 209-608-788-
000

SUBSCRIBED AND SWORN to before me this 2 nd day of September 2014 in

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

NOTARY PUBLIC
Doc. No. ________
Page No ________
Book No. ________
Series of 2014 ____