REPUBLIC OF THE PHILIPPINES)

CITY OF ROXAS . . . . . . . . . . . . .) S.S.

AFFIDAVIT OF LOSS

I, JUANA DELA CRUZ, of legal age, Filipino, married and a resident of

Poblacion, Sapian, Capiz, under oath, depose and state:

1. That, I was issued by the Bureau of Internal Revenue of an

identification card bearing my Tax Identification Number
with No. 000000000;

2. That, when I looked for said identification card in my

wallet where I normally place it, I could no longer find the
same;

3. That, despite numerous diligent efforts to find the said

identification card, I could no longer locate it up to the
present and I believe that it is already lost and beyond my
recovery;

4. That, I execute this affidavit to attest to the truthfulness of

the foregoing facts and to help support my request for a
new Tax Identification Card form the Bureau of Internal
Revenue.

IN WITNESS WHEREOF, I have hereunto affixed my signature this

________________ at the City of Roxas, Capiz, Philippines.

JUANA DELA CRUZ

Affiant

SUBSCRIBED AND SWORN TO before me, a Notary Public commissioned

in and for the City of Roxas, Province of Capiz, Philippines, this
_____________________ by the affiant who has satisfactorily proven to me her
identity through her UMID with No. CRN-0111-1111111 and who appeared and
signed the foregoing AFFIDAVIT OF LOSS in my presence within my jurisdiction,
and who avowed to the truth of its contents under the penalty of law.

Doc No.______;
Page No._____;
Book No._____;
Series of 2018.