Republic of the Philippines )

Municiplaity of Kalibo )
Province of Aklan )

AFFIDAVIT OF LOSS DUE TO FIRE

I, JANE D. ISMAEL, of legal age, Filipino, a resident of Brgy. Pook, Kalibo, Aklan
after having been sworn to in accordance with law, hereby depose and allege, that:

1. That on September 15, 2019 our stall located at Premium Stall No. 28
Premium at the Kalibo Public Market was burned and destroyed by fire;

2. As a result of the fire, most of my belongings and personal properties

including the following important documents were destroyed or lost, to wit:

 BIR Registration Permit

 BIR Book of Records
 BIR Official Receipt Booklets

3. I am executing this affidavit to inform those concerned about the loss and
destruction of the above-mentioned items or documents;

4. I attest to the truth of the foregoing facts.

IN WITNESS WHEREOF, I hereunto affix my signature this 26 th day of

September, 2019 at Kalibo, Aklan.

JANE D. ISMAEL
Affiant
OSCA ID No. KLO-016340

SUBSCRIBED AND SWORN to before me on the date and place indicated

above. Affiant exhibited before me her identification card as indicated below her signed
name.

Doc. No.
Page No.
Book No.
Series of 2019.