REPUBLIC OF THE PHILIPPINES]

CITY OF BACOLOD ] S.S.

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

AFFIDAVIT

I, ________________, Filipino, single, of legal age, with address at

___________ after being duly sworn according to law, hereby depose and state:

1. I have applied for a Taxpayer Identification Number (TIN) with the Bureau of
Internal Revenue, Bacolod City last ________________ and that I am the same
person registered under TIN __________ before the Bureau of Internal Revenue,
Bacolod City;

2. That as such, I was supposed to be issued by said Office with a TIN Card,
unfortunately, the same was not claimed by me because
___________________;

3. That I am executing this affidavit to attest to the truth and veracity of the
foregoing and to support my application for the issuance of a TIN Card from the
Bureau of Internal Revenue, Bacolod City and not to defraud anybody.

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

___________________.

___________________________
Affiant

SUBSCRIBED AND SWORN to before me this _____________________ at

__________________, affiant personally appeared before me and exhibited her
government-issued identification card with number ______________ valid until
___________ bearing her photograph and signature.

Doc. No. ____;

Page No. ____;
Book No. ____;
Series of 2022.