REPUBLIC OF THE PHILIPPINES )

Province of Leyte ) S.S.

Municipality of Villaba )
x-------------------------x

AFFIDAVIT OF LOSS
I, RICHARD VELOSO, Filipino, married, and resident of Brgy. Silad, Villaba, Leyte,
Philippines, after being duly sworn according to law, hereby depose and state that:

1. I am the holder of INCOME TAX FORMS with numbers as follows:

12/31/2013 RCS O 089007347703 02/08/2014 2551M
11/30/2013 RCS O 089007170570 01/04/2014 2551M
10/31/2013 RCS O 089006985506 12/07/2013 2551M
06/30/2012 RCS O 089004332086 08/04/2012 2551M
06/30/2011 RCS O 089002540802 08/06/2011 2551M
11/30/2010 RCS O 089001572538 01/08/2011 2551M
10/31/2010 RCS O 089001456587 12/11/2010 2551M
09/30/2010 RCS O 089001330505 11/06/2010 2551M
12/31/2009 RCS O 089000307549 03/19/2010 2551M
11/30/2009 RCS O 089000214825 03/13/2010 2551M

2. Sometime on November 8, 2012, I lost the above INCOME TAX FORMS with
numbers due to the devastating typhoon Yolanda;

3. Despite diligent efforts exerted, I could no longer locate, find or recover the said
INCOME TAX FORMS, and to the best of my knowledge, the same are now lost beyond
recovery.

4. The said INCOME TAX FORMS have not been confiscated by any officer of the
law or the issuing office or agency due to the violation of any law, statute, order, rule or regulation.

5. In the event that the lost INCOME TAX FORMS should hereafter be found or
located, I undertake to forward or surrender the same to the company for appropriate disposal.

6. I am executing this Affidavit to attest to the truth of the foregoing statements to

inform the BIR and other concerned agencies of the circumstances of the loss of said INCOME
TAX FORMS, and for whatever legal purpose that this affidavit may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this 4th of September, 2017 at
Villaba, Leyte.
____________________________
RICHARD VELOSO
Affiant
Drivers License No.: H03-97-029084
Issued on: January 14, 2016
Issued at: LTO Palompon

SUBSCRIBED AND SWORN to before me this 4th of September, 2017, affiant who are
personally known to me (or whom I had identified through competent evidence of identity) and
who exhibited to me his Competent Evidence of Identity as indicated above.

NOTARY PUBLIC
Doc. No. ______;
Page No. ______;
Book No. ______;
Series of ______.