REPUBLIC OF THE PHILIPPINES )

PROVINCE OF SURIGAO DEL NORTE)S.S.

CITY OF SURIGAO )

AFFIDAVIT OF LOSS

I, JACKELYN FERNANDEZ, of legal age, Filipino, a resident of

Purok 5B, Poblacion, Cagdianao, Dinagat Islands, after having been duly
sworn to according to law hereby depose and state:

That I am a holder of Taxpayer Identification No. (TIN) ID card,

issued by Bureau of Internal Revenue (BIR), Surigao City, Surigao del
Norte;

That sometimes on December 16, 2021, due to Super Typhoon

Odette, the said TIN ID issued by the BIR was mutilated and lost while in
my possession;

That I tried to locate the said ID, but despite of diligent effort, I
could not find the same and I consider it as lost and beyond recovery;

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

the foregoing facts and circumstances and for whatever legal purpose/s
it may serve best;

IN WITNESS WHEREOF, I have hereunto set my hand this 25 th day

of September, 2023 at Surigao City, Surigao del Norte.

JACKELYN FERNANDEZ
Affiant

SUBSCRIBED AND SWORN to before me this 25 th day of

September, 2023 at Surigao City, Surigao del Norte, Philippines.

DOC NO. _____;

PAGE NO. _____;
BOOK NO. _____;
SERIES of _____.