QF/BPLO/C010/0

REPUBLIC OF THE PHILIPPINES )

CITY OF NAGA ) SS

AFFIDAVIT OF BUSINESS CLOSURE/RETIREMENT

I, _______________________ of legal age,_________, Filipino, with residence and postal address at

___________________________________________, after having been duly sworn to in accordance
with law, do hereby depose and say:

That I am the owner/ representative of a business establishment named ________________

_________________________________ with account no. _________________ located at
________________________________________ Naga City.

That I have been issued a BUSINESS PERMIT (PAHINTULOT SA PANGANGALAKAL)

on_______________________________ by the City Government of Muntinlupa;

That on ____________________, I closed the said business due to:

____ transfer of business

____ change ownership
____ lack of capital
____ lack of manpower
____ medical condition
____ bankruptcy
____ others (pls. specify) _______________________________________________________

That I execute the foregoing instrument in order to attest the truth of the above facts for all legal
intents and purposes it may serve.

AFFIANT FURTHER SAYETH NAUGHT.

________________________
Affiant

SUBSCRIBED AND SWORN to before me this _________ day of ___________, 20_____ in the City of
Naga, affiant having exhibited to me his/her Community Tax Certificate No. ________________ issued at
___________________ on __________________________.

Doc. No. ______

Page No. ______
Book No. ______
Series of ______