Republic of the Philippines )

City of Tarlac )

AFFIDAVIT OF LOSS

I, NOEL J. GERONIMO, of legal age, married, and a resident of Palimbo Caarosipan,

Camiling, Tarlac after being duly sworn according to law, do hereby depose and state that:

1. I am the owner of MARK AND CHRIS BUYING PALAY, with business address
located at Poblacion Sur, Mayantoc, Tarlac;

1. That I am the owner of R.L.J. ALUMINUM WORKS located at #563 Purok 3,

Provincial Road, Brgy. Bucot (In front of Sinchioco Calibration), Aliaga, Nueva
Ecija;

2. That R.L.J. ALUMINUM WORKS was duly registered with the Bureau of Internal
Revenue (BIR) with Tax Identification No. 702-407-940-000 and was therefore
issued a BIR CERTIFICATE OF REGISTRATION (BIR Form 2303);

3. That unfortunately, the original copy of BIR Certificate of Registration issued by the
BIR RDO 23A was lost and I took pains to look for the original copy of said BIR
Certificate of Registration but to no avail;

4. That I am executing this affidavit to support my request with the Bureau of Internal
Revenue (BIR) for the reissuance of a new BIR Certificate of Registration and for
whatever legal purpose it may serve.

IN WITNESS WHEREOF, I have hereunto set my signature this __ day of _____, 2018
at Cabanatuan City.

LEAH RIVERA JACOBE

Affiant
ID No: ________________
Issued by: _____________

SUBSCRIBED AND SWORN to before me at the place and date above stated. I hereby
certify that I personally examined the affiant and am convinced that she voluntarily executed the
foregoing affidavit, read the same and understood its contents.

WITNESS MY HAND AND NOTARIAL SEAL.

Doc. No.: __;

Page No. __;
Book No. __;
Series of 2018;

2.