REPUBLIC OF THE PHILS.

)
CITY OF ________________ ) SS

AFFIDAVIT OF LOSS

I, JUAN PROTACIO ALONZO, of legal age, with office address at 564-84 SANTO
DOMINGO STREET ZONE 98 BARANGAY 623 SAN ANDRES MANILA 1003 after having
duly sworn hereby depose and state;

1. That I, JUAN PROTACIO ALONZO, the Licensed Customs Broker and Authorized
representative under JHUSTUNG FAST CUSTOMS BROKERAGE of Consignee,
RLSROM TRADING.

2. That the RLSROM TRADING have shipment under BL# SITTAGOI103269 with
Entry No. C12565 STC 1X20 25MT CITRIC ACID ANHYDROUS
BP/IP/UJP/JFFA/FCC/E320 31-200MESH.

3. That as the Representative, have the original Certificate of Origin Form E and is
nowhere to be found and lost due to negligence of the Representative.

4. Despite diligent search and best efforts to find the said document, I failed to locate
and recover the said document.

5. That this undertaking has no intention to violate any applicable provisions of the Tariff
and Customs Code of the Philippines and any other Laws, Rules and Regulations
related thereto.

6. That, I am executing this affidavit of lost in order to attest the truth of all foregoing and
for whatever legal and useful it may serve.

7. We undertake to assume full responsibility and relieve/free the BOC Personnel from
whatever consequences or liability that may result from the approval of the request of
and release of the shipment.

FURTHER AFFIANT SAYETH NAUGHT.

IN WITNESS OF THE TRUTH OF THE FOREGOING, I have signed this document at

_____________ on ____________.

Juan Protacio Alonzo

Affiant

SUBSCRIBED AND SWORN TO BEFORE ME, this _______ day of August 2023 in
City/Municipality of ______________.

DOC NO..________
PAGE NO.________
BOOK NO.________
Series of 2023