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REPUBLIC OF THE PHILIPPINES…)

ROXAS CITY, CAPIZ…………………....)S.S.

AFFIDAVIT

I, XXXXXXXXXXXXXXX, Filipino Citizen, of legal age, married and with postal


address at Poblacion Tacas, Cuartero, Capiz, after being duly sworn in accordance
with law, depose and state that:

1. That, I am an Owner of the business name “XXX’ FARM IMPLEMENTS & REPAIR
SHOP” which is registered with the Department of Trade and Industry (DTI)
pursuant to the provisions of Act 3883, as amended by Act 4147 and RA 863;

2. That, I was issued a Certificate of Business Name Registration which is valid from 09
January 2013 to 09 January 2018;

3. That recently, when we looked for the original copy of the said DTI Certificate
Business Name Registration, the same could not be found and must have been lost
and destroyed by reason of the flood that affected our house because of Typhoon
Agaton and that despite of diligent search and efforts, the same could no longer be
found such that I now believe that it is lost beyond recovery;

4. That, I execute this affidavit to help support my request for renewal of my business
name registration before the DTI;

5. That, I execute this affidavit to attest to the truthfulness of the foregoing facts.

IN WITNESS WHEREOF, I have hereunto set my hand this


_______________________ at Roxas City, Capiz, Philippines.

XXXXXXXXXX
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 his identity through her TIN
0000000 and who appeared and signed the foregoing AFFIDAVIT 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.

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