Republic of the Philippines]

City of Legazpi ] s.s.

x------------------------------------------x
AFFIDAVIT OF CANCELLATION/
CLOSURE OF BUSINESS NAME

I, ________________________, of legal age, Filipino citizen, (civil status), with

address at __________________________, after having been duly sworn to in accordance
with law do hereby depose and state:
1. I am the owner of (name of business) located at _____________________ with
Certificate No. ______________ registered before the Department of Trade and
Industry;
2. I have not commenced operation of under said name and opted to relinquish the
same and for said reason I would like to apply for the cancellation of said business
name;
3. My business is free from liens and encumbrances and we have no creditors
because we have not commenced operation;

4. I am executing this affidavit for the purpose of cancellation/closure of business;

and

5. I attest to the truthfulness of this affidavit.

IN WITNESS WHEREOF, I have hereunto set my hand this

__________________________ at Legazpi City, Philippines.

____________________________
Affiant
ID No. _____________________
Issued by: ____________________

SUBSCRIBED AND SWORN to before me this ___________________at Legazpi City,

Philippines. Affiant exhibited to me his/her Identification Card indicated below his/her name
bearing his/her photograph and genuine signature as competent proof of his/her identity
pursuant to 2004 Rules on Notarial Practice.

Doc. No. ______;

Page No. ______;
Book No. ______;
Series of ______.