REPUBLIC OF THE PHILIPPINES )

PROVINCE OF NORTHERN SAMAR )S.S.

MUNICIPALITY OF CATARMAN )
x-----------------------------------------x

AFFIDAVIT OF LOSS

I, __________________, of legal age, Filipino and with residence

and postal address at Brgy. Bugay, Las Navas, Northern Samar, Philippines,
after having been duly sworn to in accordance with law depose and say:

That I am a lawful holder of Tax Identification Number (TIN) Card

which was unfortunately lost by me and diligent efforts in search of the
same proved futile;

That I am executing this affidavit to attest to the truth of the foregoing

circumstance and for other legal purpose this may serve best.

IN WITNESS WHEREOF, I have hereunto set my hand this

________, in Catarman, Northern Samar, Philippines.

__________________
Affiant

SUBSCRIBED AND SWORN to before me this ___________, in

Catarman, Northern Samar, Philippines, by affiant who is known to me to be
the same person who executed and personally signed the foregoing
instrument before me and avowed under penalty of law to the whole truth of
the contents of said instrument.

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 2023.