REPUBLIC OF THE PHILIPPINES

CITY OF TAGBILARAN
AFFIDAVIT OF SURRENDER

I, ________________________________, Filipino, of legal age, single/married, and a

resident of ______________________________________________________, hereby depose
and state under oath, that:

1. I am the duly registered owner of the business name

________________________________, with Certification No. ___________
issued by the Department of Trade and Industry on _________________ with
expiry date on ______________________;

2. I have been engaged in the business of

_________________________________________, using the aforementioned
registered business name in accordance with Act 3883, otherwise known as the
Business Name Law;

3. I intend to discontinue/refrain from engaging in business using the said business

name because of:
( ) Bankruptcy/Insolvency ( ) Change of business name
( ) Change line of business ( ) Migration
( ) Closure of business ( ) Revocation of permit by other government agency
( ) Erroneous entry ( ) Making any false statement
( ) Failure to operate within 6 months ( ) With Fair Trade Law violation final and executory
( ) Immortal, illegal or unlawful activity decision
( ) Inimical to the security of the state ( ) Change of territorial scope from ____________-
( ) Not publicly used/exposed ___ to ______________

4. I am surrendering herewith the business name certificate and filled-up PBR

application form as previously issued and submitted;

5. This is an act done to defraud anybody, nor do I have outstanding obligations to

any creditor at the time of the execution of this Affidavit;

I execute this Affidavit to attest the truth of the foregoing and for any and all legal
purposes this may serve;

___________________

Affiant

SUBSCRIBED AND SWORN TO before me this ______________ day of

___________________ affiant exhibited to me his/her Community Tax Certificate/(indicate type
of ID) Identification Certificate No. ___________________ issued on
_____________________________ by ______________________________ at
__________________________.

NOTARY PUBLIC

Doc No. _________

Page No. ________
Book No. ________
Series of ________