REPUBLIC OF THE PHILIPPINES

PROVINCE OF NORTHERN SAMAR

MUNICIPALITY OF CATARMAN)

)
)S.S.

AFFIDAVIT OF LOSS
I, ________________________, of legal age, Filipino and with
residence and postal address at __________________, 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
bearing number __________________, which 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.

___________________
Affiants Signature

SUBSCRIBED AND SWORN to before me this ___________, in

Catarman, Northern Samar, Philippines, by affiant, 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 2015.