REPUBLIC OF THE PHILIPPINES

BULACAN

AFFIDAVIT OF BUSINESS CLOSURE/RETIREMENT

I, , of legal age, married, Filipino, with residence and postal
address at
after having been duly sworn to in accordance with law, do hereby depose and say:

That I am the owner/representative of a business establishment named

, with Business Permit No. located at
.

That I have been issued a BUSINESS PERMIT on by the City

Government of Bulacan.

That on , I closed the business due to:

transfer of business
change of ownership
lack of capital
lack of manpower
medical condition
bankruptcy
x others (please specify):

That I execute foregoing instrument in order to attest the truth of the above facts for all
legal intent and purpose it may serve.

AFFIANT FURTHER SAYETH NAUGHT.

AFFIANT

SUBSCRIBED AND SWORN to before me this day of , 20 in the City

Municipality of , affiant having exhibited to me his/her Community Tax Certificate
No. , issued at on .

NOTARY PUBLIC

Doc No.
Page No.
Book No.
Series of 2020