Republic of the Philippines )

City of ______ ) S.S.

AFFIDAVIT OF LOSS

I, ________________, of legal age, Filipino, and a resident of ______________,

Philippines, after having been duly sworn in accordance with law, do hereby depose
and state that:

1. I am one of the heirs of the late ___________________ doing business under

the name and style of “__________” with principal office in ________________;

2. As such sole proprietor, he had registered his business with the Bureau of
Internal Revenue (BIR) and was in possession of several official receipts;

3. We discovered recently that official receipt Booklet ___, comprising of Official

Receipt Nos. ______ is missing;

4. Diligent efforts were exerted to find the said missing booklets but to no avail such
that I believe the same are now lost and beyond recovery; and

5. I am executing this affidavit in order to attest to the truth of the foregoing

statements and to facilitate the closure of the late _______ BIR registration and
for whatever legal purposes this may serve.

IN WITNESS WHEREOF, I have hereunto affixed my signature this

_____________ in _______, Philippines.

_____________
Affiant

SUBSCRIBED AND SWORN TO BEFORE ME, a Notary Public for the City of
________, affiant exhibited to me competent evidence of his identity as follows:
________________________; and I am convinced he executed the foregoing freely
and voluntarily.

WITNESS MY HAND AND SEAL.

Doc. No. ___

Page No. ___
Book No. ___
Series of 20__.