REPUBLIC OF THE PHILIPPINES )

PROVINCE OF ILOILO ) SS.

AFFIDAVIT OF LOSS

I, __________________, of legal age, married, Filipino and a resident of

_______________________after having been duly sworn in accordance with law, hereby depose
and say:

1. That I am the proprietor/owner of ____________ engaging in the business of selling

school and office __________________________________________;

2. That sometime on August 2018 while I was processing my Certificate of Registration

with the Bureau of Internal Revenue in Iloilo City, I brought with me the original copy of
the DTI Certification of our business under the trade name Learning Helps;

3. That after I processed my Certificate of Registration, I placed and secured the DTI
Certification inside the folder in my bag;

4. That upon checking my DTI Certification in the folder yesterday to process my

business permit, the said document was nowhere to be found;

3. That diligent efforts to locate and search in the store and in my residence were made,
but, unfortunately, the Original Copy of the DTI Certification was nowhere to be found;

4. That the said DTI Certification is required for the processing of Business Permit of
_______________________;

5. I am executing this affidavit to attest to the truth of the above statement of facts and
for whatever legal purposes this may serve;

IN WITNESS WHEREOF, I have hereunto affixed my signature this 10th day of January
2019 at _______________________, Iloilo, Philippines.

_________________________________
Affiant

SUBSCRIBED AND SWORN TO BEFORE ME, a notary public this 10TH day of
January 2019. Affiants personally came and appeared with
__________________________________ issued at __________________________, Philippines,
bearing her photograph and signature, known to me as the same person who personally signed the
foregoing instrument before me and avowed under penalty of law to the whole truth of the contents
of said instrument.

Doc. No. ___________:

Page No. ___________:
Book No. __________:
Series of 2019
 January 10, 2018

ENGR. DIOSDADO P. CADEÑA, JR.

Provincial Director
DTI- Iloilo

Dear Engr. Cadeña,

Greetings!

I, ___________________ of legal age, married, Filipino and a resident of Brgy. _______

and the owner/proprietor of _________________________________.

I am writing this letter to your good office for the re-issuance of DTI Certification for
____________ which was lost sometime on August 2018 when I was processing my Certificate of
Registration with BIR.

I am humbly hoping that favorable action be merited on my request. God Bless and More
Power!

__________________
Owner/ Proprietor