REPUBLIC OF THE PHILIPPINES )

PROVINCE OF ___ )S.S.

MUNICIPALITY OF ____ )

AFFIDAVIT OF LOSS - TOP

That I, ________., of legal age, Filipino Citizen, and resident of ______, after
having been duly sworn to in accordance with law do hereby depose and say:

That I am a holder of Temporary Operating Permit (TOP);

That due to inadvertence said Temporary Operating Permit (TOP) has been
lost sometime in the year __ at ____, and in spite of all effort by me with due diligence
to find the same, I have been unable to locate up to this time. That being not able to
locate said Temporary Operating Permit (TOP) the same is now presumed lost
forever.

IN WITNESS WHEREOF, I hereunto set my hand this __________________ at

___, Philippines.

____.
Affiant

SUBSCRIBED AND SWORN TO BEFORE ME this ______________________

at Bangued, Abra, Philippines. Affiant exhibited and was identified by me through his
___

Doc. No. ______ NOTARY PUBLIC

Page No. ______
Book No. ____
Series of 2022