Republic of the Philippines.

)
Province of Surigao del Norte ) S.S.
Municipality of Socorro )
x-------------------------x

AFFIDAVIT OF LOSS

I,_____________, Filipino, of legal age,(single / married / widow),and a resident of

_____________, Philippines, after being duly sworn in accordance with law, depose and state:

That I am the ____________of___________, a corporation duly organized and existing under

and by virtue of the laws of the Republic of the Philippines.

That being registered with the Bureau of Internal Revenue,_____________has been issued a BIR
Certificate of Registration;

That sometime in____________, the original copy of the said BIR Certificate of Registration
could not be found and that despite of diligent search and efforts, the same could no longer be
found such that I now believe that it is now lost beyond recovery.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing and for
whatever legal purposes that this may serve.

IN WITNESS WHEREOF,I have hereunto set my hand this _____________at_____________,

Philippines.

AFFIANT