REPUBLIC OF THE PHILIPPINES)

Province of ____________________) S.S.

City/Municipality of _____________)
x-----------------------x

AFFIDAVIT OF LOSS

I, _____________________________, Filipino, of legal age, (single / married /

widow), and a resident of
_______________________________________________________________________,
Philippines, after being duly sworn in accordance with law, depose and state:

1. That I am the holder of a ___________________________________ issued

by the Business Permit and Licensing Office (BPLO) ___________________;

2. That sometime on ____________________________, the

___________________________ could not be found and that despite of
diligent search and efforts, the same could no longer be found such that I
now believe that it is now lost beyond recovery.

3. 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 _____________ at

_____________, Philippines.

_____________________________
Affiant

SUBSCRIBED AND SWORN to before me, this _____________, by the Affiant who is
personally known to me and whom I have identified through competent evidence of identity
No. __________________________ issued by _________________________ on

NOTARY PUBLIC
Doc. No. ______;
Page No. ______;
Book No.______;
Series of 2017.