Republic of the Philippines)

DONE: CITY OF BAGUIO…..) S.S.

AFFIDAVIT OF LOSS
I, MARLENE A. CABINTA, of legal age, Filipino Citizen with residence and
postal address at #528 Badihoy St., Pinsao Proper, Baguio City, Philippines, after
having been duly sworn to in accordance with law do hereby deposes and states
that:

1. I am engaged in business particularly eatery business located at Puguis, La

Trinidad, Benguet and I duly registered it with the Bureau of Internal Revenue
(BIR), hence, CERTIFICATION OF REGISTRATION, NOTICE OF ASK
RECEIPT and OFFICIAL RECEIPTS were issued;

2. On April 8, 2022, my eatery was burned into ashes, hence, I was forced to
closed it. Included in those things burned were the CERTIFICATE OF
REGISTRATION, NOTICE OF ASK RECEIPT and OFFICIAL RECEIPTS
(unused). I exerted diligent effort to retrieve some important things and
documents inside the eatery but I failed due to the fire, hence, lost forever;

3. The said CERTIFICATE OF REGISTRATION, NOTICE OF ASK RECEIPT and

OFFICIAL RECEIPTS (unused) were not been given nor pledged to anyone for
any purpose whatsoever, nor were taken or confiscated by the authorities;

4. I am executing this affidavit to attest to the truthfulness of the foregoing facts

and for all legal intents and purposes that it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this ______ th day of

_________________, 2022 at Baguio City, Philippines.

MARLENE A. CABINTA
AFFIANT
BIR TIN No. 936-310-354
Issued On: 11-03-2021

SUBSCRIBED AND SWORN TO before me this ______th day of _______________,

2022 at Baguio City, Philippines. Affiant personally appeared before me to be the
same person who executed this instrument as her free act and deed.

Doc. No. ________;

Page No. ________;

Book No. ________;

Series of 2022.