DECLARATION OF LOSS ARISING FROM CASUALTY

Name of Taxpayer:
Business Address:
T.I.N.:
RDO No.:

A. NATURE OF LOSS
1. Event causing the loss
2. Date of occurrence of event

B. VALUATION OF LOSS
BUSINESS PROPERTY - TOTAL DESTRUCTION
Accumulated
Declared Cost of Depreciation Amount of
Description of Property Location Property (If Any) Insurance Name of Insurance
(Per Financial Recovery Company
Statement) (Per Financial Declared
Statement)

1.
2.
3.
4.
5.

BUSINESS PROPERTY - PARTIAL DAMAGE

Replacement Cost
Declared Cost of Accumulated to Restore the
Depreciation Amount of
Description of Property Location Property (If Any) Property Back to Insurance
(Per Financial (Per Financial its Normal Recovery Declared
Statement) Operating
Statement) Condition

1.
2.
3.
4.
5.
NB: To support the information provided in this Form, the following documents must be submitted:
1) Financial Statement for the year immediately preceding the event that caused the loss; and,
2) Copies of the Insurance Plan(s) for the concerned property(ies).

I am executing this Sworn Declaration to attest to the truth of the foregoing facts and for whatever legal
intents and purposes it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this ________ day of ___________________, 2009 at
_________________________________, Philippines.

Taxpayer
(Signature Over Printed Name)

SUBSCRIBED AND SWORN to before me, this _________ day of ____________, 2009 at __________________, affiant
exhibiting to me his Tax Identification No. _____________________ issued at _____________________.

NOTARY PUBLIC
Doc. No. __________
Page No. __________
Book No. __________
Series of 2009.