REPUBLIC OF THE PHILIPPINES)

CITY OF LAS PIÑAS) SS

AFFIDAVIT OF BUSINESS CLOSURE/RETIREMENT

I, PABLO A. ADIA of legal age, single, Filipino, with residence and postal address at Block 2
Lot 1 corner 15th Street and 19th Street, Golden Gate Subdivision, Talon Tres, Las Piñas City,
after having been duly sworn to in accordance with law, do hereby depose and say:

That I am the owner of a business establishment named HARLICK GENERAL

MERCHANDISE with account no. 2003020719 located at 443 Real Street, Talon Tres, Las
Piñas City.

That I have been issued a BUSINESS PERMIT on January 19, 2021 by the City Government of
Las Piñas with OR 12102011J;

That on October 31, 2021, I am closing the said business due to poor medical condition.

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

AFFIANT FURTHER SAYETH NAUGHT.

________________________
Affiant

SUBSCRIBED AND SWORN to before me this _________ day of ___________, 20_____ in

the
City of Las Piñas, affiant having exhibited to me his/her Community Tax Certificate No.
________________ issued at ___________________ on __________________________.

Doc. No. ______

Page No. ______
Book No. ______
Series of ______