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47679RMO ON CASUALTY LOSSES - DECLARATION OF LOSS - Revised
47679RMO ON CASUALTY LOSSES - DECLARATION OF LOSS - Revised
Name of Taxpayer:
Business Address:
T.I.N.:
RDO No.:
A. NATURE OF LOSS
1. Event causing the loss
2. Date of occurrence of event
B. VALUATION OF LOSS
BUSINESS PROPERTY - TOTAL DESTRUCTION
1.
2.
3.
4.
5.
NB: To support the information provided in this Form, the following documents must be submitted:
1) Financial Statement for the year immediately preceding the event that caused the loss; and,
2) Copies of the Insurance Plan(s) for the concerned property(ies).
I am executing this Sworn Declaration to attest to the truth of the foregoing facts and for whatever legal
intents and purposes it may serve.
IN WITNESS WHEREOF, I have hereunto set my hand this ________ day of ___________________, 2009 at
_________________________________, Philippines.
Taxpayer
(Signature Over Printed Name)
SUBSCRIBED AND SWORN to before me, this _________ day of ____________, 2009 at __________________, affiant
exhibiting to me his Tax Identification No. _____________________ issued at _____________________.
NOTARY PUBLIC
Doc. No. __________
Page No. __________
Book No. __________
Series of 2009.