REPUBLIC OF THE PHILIPPINES )

PROVINCE OF AGUSAN DEL NORTE ) S.S.

MUNICIPALITY OF BUENAVISTA )
X-----------------------------------------------------------)

AFFIDAVIT OF LOSS

I, RAUL E. BALIBIA, Filipino of legal age, married and a resident of Purok

3 Talo-ao, Buenavista, Agusan del Norte, Philippines, after having been duly
sworn to in accordance with law do hereby depose and say;

1. That, I am the owner of TIN Identification Card (I.D.)with number

B4165-K1968-A-7;

2. That, unfortunately, the said identification card was lost on an

undetermined date, which loss was discovered only today;

3. That efforts have been exerted by me to find, retrieve or recover said Tax
Identification Number (TIN) I.D., but to no avail , thus, I am now
convinced that it was indeed, lost beyond recovery;

4. That, I execute this affidavit for the purpose of applying for reissuance of
another Tax Identification Number (TIN) Identification Card (I.D.) of same
number;

5. That, I execute this affidavit to attest to the truth of the foregoing facts
and for whatever legal purpose this may serve best.

IN WITNESS WHEREOF, I have hereunto set my hand this ____ day

of ___________________ 2018 in Buenavista, Agusan del Norte, Philippines.

RAUL E. BALIBIA
Affiant
I.D. No:____________________
Issued by:_______________
Issued on:______________

SUBSCRIBED AND SWORN to before me this _____ day of

___________________ 2018 in Buenavista, Agusan del Norte, Philippines.

JESON D. PAGAPONG
Notary Public
Doc. No. _______ Until December 31, 2019
Page No. _______ Butuan City, Agusan del Norte
Book No: _______ PTR No. 1568715; 06/08/2018,
Series of 2018 in Butuan City
IBP OR: 043065
ATTORNEY’S ROLL NO. 70563
TIN: 721-080-498-000