Republic of the Philippines)

Malolos City, Bulacan ) S.S.

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

AFFIDAVIT OF LOSS

I, ROWENA ONG NAMORA, of legal age, married, Filipino

and with postal address at 17 Venus Street, Skyline Subdivision,
Viente Reales, Valenzuela City, after having been duly sworn to in
accordance with law do hereby deposes and states, that:
1. I am a holder of Certificate of Creditable Tax Withheld at
Source (Form No. 2307) for years of 2019 and 2021, duly
issued to me by the Bureau of Internal Revenue, Valenzuela
City Branch (RDO No. 24), located in Arca North Bldg, Mc
Arthur Highway, Karuhatan, Valenzuela City;
2. Sometime in 2021, while in our residence in Viente Reales,
Valenzuela City, upon checking of my some documents, I
noticed that the subject Form No. 2307 was missing it might
have been misplaced inside our house and I could no longer
to locate;

3. I have exerted diligent efforts to locate the same but all my

efforts proved to be all in vain; and

4. I am executing this Affidavit to attest to the truth and

veracity of the foregoing set of facts and to inform the
authorities thereof for all legal intents and purposes it may
serve.

Malolos City, Bulacan, January 21, 2022.

ROWENA ONG NAMORA

Affiant
SUBSCRIBED AND SWORN TO before me this 21 st day of
January 2022, hereat Malolos City, Bulacan. Affiant personally
appeared exhibiting to me her LTO Driver’s License with Lic. No.
N04-97-392080, that she is the same person who signed this
instrument before me and acknowledge that she executed the same.

Doc No. 501;

Page No. 102;
Book No. XX;
Series of 2022.