REPUBLIC OF THE PHILIPPINES)

CITY OF CALOOCAN ) S.S.

x---------------------------------------------x

AFFIDAVIT OF LOSS

I, ANNA MARIELLA T. BERNABE, of legal age, married, Filipino and with postal
address at 22 A. St. Jude Street, Rosalia Village 2, Tandang Sora, Quezon City, after having been
duly sworn to in accordance with law, hereby depose and say:

That around April 2019, my staff from my dental clinic conducted a general cleaning on the
same;

That a few days thereafter, I noticed that the BIR Receipt booklet with series numbers 0151-0200
was nowhere to be found;

That since then on, I have been trying to locate the said receipt booklet;

That earnest efforts were taken on my part in order to locate the above-mentioned receipt but my
efforts proved futile;

That I am attesting to the truthfulness of the foregoing facts and circumstances for whatever legal
purpose that it may serve.

IN WITNESS WHEREOF, I have hereunto affixed my signature this

_________________ in Caloocan City Philippines.

ANNA MARIELLA T. BERNABE

Affiant

SUBSCRIBED AND SWORN to before me this _____ day of ______________ 2019 in

Caloocan City, Philippines, Affiant exhibiting to me her ________________________________.

NOTARY PUBLIC

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 2019.