REPUBLIC OF THE PHILIPPINES)

_________________________) S.S.

AFFIDAVIT OF CLOSURE

I, JOHN OWEN ONG, Filipino, of legal age, and a resident of

Malaspina St., Villamonte, Bacolod City, after having been duly sworn in
accordance with law do hereby depose and state:

1. I am the Corporate Secretary of EVERSURE MAXIM INC., a

corporation duly organized and existing under and by virtue of the
laws of the Republic of the Philippines, with principal office and place
of business at 2nd Floor One Blue Rhino Bldg. Corp., H. Abellana St.,
Canduman, Mandaue City, which is registered with the Bureau of
Internal Revenue (BIR);

2. That the Corporation is applying for the closure of the branch of

EVERSURE MAXIM INC. located at Baloy, Barangay Tablon,
Cagayan de Oro City registered with the BIR in (date of registration),
with Certificate of Registration OCN No. (certificate number), which
the Corporation decided to close effective _____________;

3. That the reason for the termination is due to

_____________________;

4. That the business has no outstanding liability and obligation;

5. That I am executing this affidavit to attest to the truth of all the

foregoing statements and for whatever legal purpose it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this

_________________ at _____________, Philippines.

JOHN OWEN ONG

Affiant

SUBSCRIBED AND SWORN TO BEFORE ME this ___ day of

_________ 2019, at __________ affiant exhibited to me his TIN ID No.
196-627-118 issued on as competent evidence of his identity.

Doc. No. : ________;

Page No. : ________;
Book No. : ________;
Series of 20___.