REPUBLIC OF THE PHILIPPINES)

CITY OF ______________ ) S.S

AFFIDAVIT OF BUSINESS CLOSURE/RETIREMENT

I, [INSERT NAME OF OWNER/REPRESENTATIVE], of legal age, Filipino, and with

residence and postal address at [INSERT ADDRESS], after having been duly sworn to in
with accordance with law, do hereby depose and say:

1. That I am the owner/duly authorized representative [OR INSERT OFFICIAL

POSITION, choose which is applicable] of [INSERT NAME OF BUSINESS]
(the “Business”), a corporation [OR SOLE PROPRIETOR/PARTNERSHIP,
choose which is applicable] organized and existing under the laws of the Republic
of the Philippines, with office address at [INSERT ADDRESS].

2. That on [INSERT DATE OF ISSUANCE OF LATEST BUSINESS PERMIT

RENEWAL], the Business secured its [INSERT YEAR OF LATEST BUSINESS
PERMIT] Business Permit from the City Government of [INSERT CITY].

3. That on [INSERT DATE OF BIR REGISTRATION], that said Business

registered with the Bureau of Internal Revenue (BIR) with Certificate of
Registration OCN No. _______.

4. That I am applying for the closure/retirement of the Business, which I decided to

close and terminate its operations effective on [INSERT EFFECTIVE DATE OF
CLOSURE/RETIREMENT].

5. That the reason for the closure/retirement is due to [INSERT REASON/S FOR
CLOSING/RETIRING THE BUSINESS].

6. That the Business has no outstanding liability and obligation.

7. That I am executing this Affidavit to attest to the truth and veracity of the facts
stated herein, and for the purpose of obtaining a clearance from the City
Government of [INSERT CITY] for the closure/retirement of the Business and for
all legal intents and purposes it may serve.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ____ day of

_____________ 20__ at ____________, Philippines.

__________________________
[INSERT AFFIANT’S NAME]

SUBSCRIBED AND SWORN to before me this _____ day of _________ 20__ at

_____________, affiant exhibiting to me his/her ________________ issued on
________________, valid until _____________________.

Doc. No. ___________;

Page No. ___________:
Book No. ___________;
Series of 20__.