Republic of the Philippines

City of Tacloban

AFFIDAVIT OF LOSS

I, LORIE ROMERO, of legal age, single, Filipino, and currently a resident of

Naval, Biliran, after having been duly sworn to in accordance with law, hereby
depose and say, THAT:

1. I am the owner/proprietor of a business name LAP Gasoline Station

with business address at Calumpang, Naval, Biliran;

2. Said business enterprise is registered with the Bureau of Internal

Revenue (BIR), as such I was issued a Certificate of Registration;

3. Recently, when I looked for the original copy of the said Certificate of
Registration, the same could not be found and must have been
misplaced;;

4. Despite of diligent search and efforts, the same could no longer be

found such that I now believe that it is now beyond recovery;

5. I am executing this sworn declaration to confirm the truth of the

foregoing statements and in support of my application with the BIR
for the issuance of a new Certificate of Registration.

IN WITNESS WHEREOF, I have hereunto set my hand this 28 th day of

September 2017 at the City of Tacloban, Philippines.

LORIE ROMERO
Affiant
ID No. _____________

SUBSCRIBED and SWORN TO BEFORE ME this 28th day of September

2017 at Tacloban City, Philippines, affiant having personally shown to me her
identification card above-stated as proof of her identity.

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