REPUBLIC OF THE PHILIPPINES )

CITY OF TAGBILARAN ) S.S.

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AFFIDAVIT OF LOSS

I, JUVY S. LIM, of legal age, married, a resident of Taloto District, Tagbilaran City, Bohol, after
having been duly sworn in accordance with law hereby depose and state that:

1. I am the owner and proprietor of CRYSTAL J WATERS, a water refilling business located
in F.R. Ingles St, Tagbilaran City;

2. Sometime in January 2019, I had closed down and stopped the operations of CRYSTAL J
WATERS due to financial difficulties and setbacks;

3. Sometime in May 2019, the Pag-IBIG Fund had sent me a letter requesting me to present
FORM R-5 in order to confirm how many employees I had declared and which I had paid
the corresponding contributions;

4. After going through my files, I had realized that I had lost a copy of FORM R-5;

5. Despite my diligent and utmost efforts, the FORM R-5 cannot be found;

6. I am executing this affidavit to attest to the truthfulness of the foregoing and for whatever
purpose it may serve.

IN WITNESS WHEREOF, I have hereunto affixed my signature on this 14th day of February
2019, at Tagbilaran City.

JUVY S. LIM
Affiant
ID No. ___________________________

SUBSCRIBED and SWORN to before me this _____ day of July 2019, at Tagbilaran City. I hereby
certify that I have personally examined the above-named affiant and that I am satisfied that the
foregoing statements were given by him voluntarily and of his own free will.

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