REPUBLIC OF THE PHILIPPINES)

City of Ormoc ) S.S.

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

AFFIDAVIT OF LOSS

I, ROSITA PITOGO TUGONON, Filipino, of legal age, married, and a resident of Barangay
Mas-in, Ormoc City, Leyte, after having been sworn in accordance with law hereby depose
and state THAT:

1. I am a proprietor of SITA SARI-SARI STORE with business address in Purok

Kalipayan, Barangay Mas-in, Ormoc City, Leyte;

2. As such, I was issued a Mayor’s Permit/Mayor’s Business Permit by the Office of the
City Mayor, Ormoc City, for the year 2022;

3. Sometime in December, after making an inventory of all commodities in my store, I

realized that the original copy of my Mayor’s Business Permit for 2022 was lost. Said
document must have been thrown to the garbage bin along with the old documents;

4. Efforts were exerted to locate said Mayor’s Business Permit, but in spite of diligent
search, it could not be found and the same is now beyond recovery;

5. As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
and to support my application for new Mayor’s Business Permit the and for
whatever legal purpose this may best serve.

IN WITNESS WHEREOF, I have hereunto set my hand this _________________ in Ormoc City,
Philippines.

ROSITA PITOGO TUGONON

Affiant
Philhealth
13-025108685-1

SUBSCRIBED AND SWORN to me before this _________________________, affiant exhibited to me

her identity card stated above which serves as competent evidence of her identity.

Doc. No. _____;

Page No. _____;
Book No.______;
Series of 2022.