REPUBLIC OF THE PHILIPPINES)

C I T Y ) S.S.
X-----------------------x

AFFIDAVIT OF LOSS

I, , Filipino, of legal age, widow and a resident of Brgy., under oath hereby
depose and state:

1. That I am a former owner of one unit Ten Wheeler Truck which I used in
trucking business;

2. That I applied with the Bureau of Internal Revenue (BIR) and with the
Department of Trade and Industry (DTI) the registration of my trucking
business name with address at and upon payment of the prescribed fees
and submission of the required documents, I was given the Certificate of
Registration by the BIR and the Official Receipt and Invoices and upon
receipt of said certification sometime I placed the same in an envelope
together with other equally important documents;

3. That because I cannot handle the management of a trucking business, I

decided to close the operation of my trucking business and sold my one
unit ten wheeler truck;

4. That with the closure of my trucking business and the passage of time all
documents pertaining to the operation of was among the documents
destroyed by flood waters that enters our house;

5. That I am now executing this affidavit to inform the BIR and other
government agencies concerned about the lost of the Certificate of
Registration, Official Receipts & Invoices of L.F.G. Trucking issued to me
by the BIR and the closure of my trucking business;

6. That I further execute this affidavit to attest to the veracity of the foregoing
facts and for whatever legal purpose this may serve;

IN WITNESS WHEREOF, I have hereunto affixed my signature this 25 th

day of September, 2012 in the

Affiant

SUBSCRIBED AND SWORN to before me this 25 th day of September,

2012 in the, Nueva Ecija.