Republic of the Philippines)

_____________________) s.s.

AFFIDAVIT OF LOSS OF BUSINESS PLATE

I, __________________, of legal age, Filipino, married, and with residence located at

________________________________________________________________________, after
having sworn to in accordance with law, hereby depose and state that:

1. I am the registered owner of a business under the trade name

__________________;

2. Being registered with the City of __________________, __________________ has

been issued a Business Plate under Business Permit Account No.
__________________;

3. On __________________, I, together with some other persons, packed all the

unsold stocks of __________________, as well as its business supplies and
documents, and transferred them to its new location at __________________;

4. As far as I remember, I put the said Business Plate in one box together with the
other business supplies and documents;

5. However, sometime in __________________, upon preparation of all the required

documents for the business closure of __________________, the said Business
Plate could not be found;

6. Despite diligent search and efforts to locate the said Business Plate, I could not
find the same such I believe it is now lost beyond recovery;

7. As such, I am executing this affidavit to attest to the truthfulness of the foregoing

and for whatever legal purpose it may serve.

IN WITNESS WHEREOF, I hereby affix my signature this _______________ at

_______________________.

__________________
Affiant

SUBSCRIBED AND SWORN TO BEFORE ME this _______________ at

_________________________ affiant exhibiting to me her ______________ ID No.
_____________, bearing her photograph and signature and avowed the truthfulness of
the foregoing declarations.

Doc. No. ____

Page No. ____
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Series of ____