REPUBLIC OF THE PHILIPPINES)

CITY OF NAGA. . . . . . . . . . . . . . . . . )S.S.

AFFIDAVIT OF LOSS
I, EVERLY FRANZ P. CAPSA, of legal age, single, Filipino citizen with residence and
postal address at Block 27 Lot 1 Deca Homes Langon Vista, Cararayan, Naga City, Camarines
Sur, after having been duly sworn in accordance with law, hereby depose and say;

THAT I WAS A HOLDER OF:

CERTIFICATE OF REGISTRATION (COR)

BUSINESS NAME: EVER-CAPSA ONLINE-CLOSET & UKAY-BALES CLOTHING

WHOLESALING;

REGISTERED NAME: CAPSA, EVERLY FRANZ P.

TIN AND BRANCH CODE: 311-385-412-00000

ISSUED TO ME BY:

BUREAU OF INTERNAL REVENUE

THAT SAID ITEM/S WAS/WERE LOST LAST

FEBRUARY 2023

HOW:

MISPLACED

and despite diligent efforts I have exerted to look for it. The same can no longer be
found.

That I am executing this affidavit to attest the fact of loss and for purpose of:

FOR REQUEST CERTIFICATE OF REGISTRATION (COR)

IN WITNESS WHEREOF, I hereby affix my signature this________________ at Naga

City, Camarines Sur, Philippines

EVERLYN FRANZ P. CAPSA

Affiant

SUBSCRIBED AND SWORN to before me this_______________ at Naga City,

Camarines Sur, Philippines.

Doc. No._________;
Page No.________;
Book No.________;
Series of 2023.