REPUBLIC OF THE PHILIPPINES)

CITY OF DIPOLOG )S.S

x-------------------------------------------/

AFFIDAVIT OF LOSS

KNOW ALL MEN BY THESE PRESENTS:

I, MYRLO V. ELIC, Filipino, of legal age, married, and a resident of Mauswagon,

La Libertad, Zamboanga del Norte, after having sworn to in accordance with law,
depose and say that:

I had been in possession of an Original Copy of the Certificate of Registration

issued by the Bureau of Internal Revenue (BIR) or form No. 2303 issued under my
name;

The original copy of the above-mentioned document was lost sometime in

March;

Despite earnest efforts exerted by me, the same could no longer be found nor
recovered;

I am executing this affidavit in good faith and in accordance with law, to attest to
the fact of the loss of aforementioned document.

IN WITNESS WHEREOF, I have hereunto affixed my signature this 14 th day of

July, 2021 at Dipolog City, Philippines.

MYRLO V. ELIC
Senior Citizen’s ID No. La Lib-21-04-100
Affiant

SUBSCRIBED, SIGNED, AND SWORN TO in my personal presence, this 14 th of

July, 2021, at Dipolog City, Philippines, affiant presenting his competent proof of
identity, the particulars of which are above-cited, and who avowed under penalty of
law to the whole truth of the contents of the instrument or document, which he
executed freely and voluntarily.

Doc. No. _____;

Page No. _____;
Book No._____;
Series of 2021.