Affidavit of Loss DTI Certificate of Registration)

Republic of the Philippines)

Province of ____________________)S.S.
City/Municipality of _____________)
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 an Owner of the business name "_____________" which is registered with the
Department of Trade and Industry (DTI) pursuant to the provisions of Act 3883, as amended by
Act 4147 and RA 863;

That I was issued a Certificate of Business Name Registration on _____________ with No.
_____________ which is valid from _____________ to _____________;

That recently, when we looked for the original copy of the said DTI Certificate Business Name
Registration, the same could not be found and must have been misplaced 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 Affidavit may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this _____________ at _____________,

Philippines.

AFFIANT

(JURAT)