REPUBLIC OF THE PHILIPPINES)

) S.s.
x--------------------------------------------------x

AFFIDAVIT OF LOSS

I, __________, of legal age, single, and a resident of ____________________,

hereby depose and state under oath the following:

1. I am employed as a ________ of _____________.;

2. I was the one who processed the Tax Bidding Clearance of
__________, with the BIR, with claim stub control no. ____,
processed on ____, and with release date on _____.
3. Sometime on October 24, 2017, when I arrived to work, I discovered
that the claim stub was no longer in the file folder where I placed it;
4. The said claim stub is irretrievably lost and can no longer be found
despite diligent efforts to locate the same;
5. I am requesting that the same be replaced or that I be allowed to claim
________.s tax clearance from BIR.
6. I am executing this Affidavit to attest to the truth of the foregoing.

IN WITNESS WHEREOF, I have hereunto signed my name below, this 25th

day of October at Taguig City.

______________________
Affiant

SUBSCRIBED AND SWORN to before me, this ___ day of October 2017.
Affiant exhibited to me his ________________________.

Doc. No. _____;

Page No. _____;
Book No. ____;
Series of 2017