Republic of the Philippines )

Dumaguete City ) S.S.

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

AFFIDAVIT OF LOSS
I, ANACORITA E. VALENCIA, of legal age, Filipino, widow, and a resident of Datag,
Siaton, Negros Oriental, after having been duly sworn to in accordance with law, do hereby
depose and state THAT:

1. I am the registered holder of a CERTIFICATE OF REGISTRATION for the business

entity with trade name Anacurita’s Store issued by the Bureau of Internal Revenue (BIR)
with OCN No. 2RC0000307763 and covered under Tin No. 176-846-760-001;

2. Five years ago, such business entity closed and ceased its operations. Consequently, the
abovementioned Certificate of Registration covering the business entity was misplaced
and can no longer be found;

3. Despite diligent search and efforts to locate the said Certificate of Registration, it could
not be found such that I now believe that it is lost beyond recovery;

4. As such, I am executing this Affidavit of Loss freely and voluntarily, to attest, affirm, and
declare the cause of the loss of abovementioned Certificate of Registration, and for
whatever legal purposes this may serve best.

IN WITNESS WHEREOF, I have hereunto set my hand this 16th day of September, 2020 at
Dumaguete City, Philippines.

ANACORITA E. VALENCIA
Affiant
Identification Card: OSCA I.D.
Identification Card Number: 1165

SUBSCRIBED AND SWORN TO BEFORE ME, this 16th day of September, 2020 in
Dumaguete City.

Doc. No._____
Page No.____
Book No. ____
Series 2020.