Republic of the Philippines )

City of ______ ) S.S.

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

AFFIDAVIT OF CLOSURE OF BUSINESS OPERATION

I, _________________, of legal age, single/married/widow, Filipino citizen, and presently residing

at _____________________, after having been duly sworn to in accordance with law, do hereby depose
and say:

1. That I am the (state position) of (state business name) located at (state business address);

2. That said business is registered with the Bureau of Internal Revenue (BIR) on ____________
with Certificate of Registration OCN No. _______;

3. That I am applying for the termination of the business ___________ effectively on

_____________ because (state reason for closing the business);

4. That the business has no outstanding liability and obligation;

5. That I am executing this affidavit to attest to the truth of all the foregoing statements and for
whatever legal purpose it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this ____ day of _______ 2014 at ______________,
Philippines.

________________

Affiant

SUBSCRIBED AND SWORN to before me this ____ day of ______ 2014 in _________, Philippines, affiant
exhibiting to me his/her competent evidence of identity by way of _______________ issued at
___________ on ________________.

Notary Public

Doc No. : _____

Page No.: ______
Book No.: ______
Series of 20______