Republic of the Philippines )

City of Iloilo ) S.S.

AFFIDAVIT OF LOSS

I, SHEILA S. NAVALTA, of legal age, married, Filipino and a resident of Brgy. Buyo, Sta.
Barbara, Iloilo, Philippines, after being sworn in accordance with law, depose and say:

1. That I am the owner of Froilan Sari-Sari Store, located at Brgy. Buyo, Sta. Barbara, Iloilo;

2. That the said store was registered with the Bureau of Internal Revenue and was issued a
Certificate of Registration;

3. That relative to the above-mentioned registration, I have in my costudy the following

documents, to wit:

a. Original Ask for Receipt/Claim Slip for unclaimed Ask for Receipt;
b. Filled-up BIR from 1905 and validated by the ONETT;
c. Income Tax Return (ITR) and receipts;
d. Percentage Tax Return and receipts;
e. Delinquency Report;
f. Unused receipts and invoices

4. That lately, the copies of the above-mentioned documents, including the original copy of the
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 and beyond
recovery;

5. That I am executing this affidavit to attest to the truth of the foregoing and for any legal
purpose it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this _____day of ____________, 2022 in
the City of Iloilo, Philippines.

SHEILA S. NAVALTA
Affiant

SUBSCRIBED AND SWORN to before me this ____ day of _____________, 2022, in the City of
Iloilo, Philippines. Affiant exhibiting to me her Identification Card Number ____________ issued on
______________ at _________________.

WITNESS MY HAND AND NOTARIAL SEAL on the day, year and place first above-written.

Doc. No.______
Page No.______
Book No.______
Series of 2022