REPUBLIC OF THE PHILIPPINES )

PROVINCE OF _ ) S.S
_ )

AFFIDAVIT

That I, ___, of legal age, Filipino citizen, widow, and a resident of ___, after
having been duly sworn to in accordance with law do hereby depose and say the
following to wit that:

1. I am the same person executing the foregoing affidavit and the same
circumstance whom they pertain;

2. I am the co-owner of the business name with business address at ___;

3. I will let ___ be named on the receipt to be issued by the BIR RDO 16;

4. That I am executing this affidavit to attest the truthfulness of the

foregoing facts and to inform the concern offices about the loss of the
aforementioned pertinent documents and further execute this affidavit
for all legal intents and legal purposes this may serve;

That I further sayeth none.

IN WITNESS WHEREOF, I have hereunto set my hand this ___ Maddela,

Quirino, Philippines

___
Affiant
Conforme:

___

SUBSCRIBED AND SWORN to before me this 29th day of April 2022 at ___,
Philippines

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