REPUBLIC OF THE PHILIPPINES )

CITY OF CABANATUAN ) S.S.

AFFIDAVIT OF LOSS
OF BIR CERTIFICATE OF REGISTRATION (COR)

I, LEAH RIVERA JACOBE, of legal age, Filipino and a resident of #563 Purok 3,
Provincial Road, Brgy. Bucot (In front of Sinchioco Calibration), Aliaga, Nueva Ecija, after
having been sworn to in accordance with law, hereby depose and state the following:

1. That I am the owner of R.L.J. ALUMINUM WORKS located at #563 Purok 3,

Provincial Road, Brgy. Bucot (In front of Sinchioco Calibration), Aliaga, Nueva
Ecija;

2. That R.L.J. ALUMINUM WORKS was duly registered with the Bureau of
Internal Revenue (BIR) with Tax Identification No. 702-407-940-000 and was
therefore issued a BIR CERTIFICATE OF REGISTRATION (BIR Form 2303);

3. That unfortunately, the original copy of BIR Certificate of Registration issued

by the BIR RDO 23A was lost and I took pains to look for the original copy of
said BIR Certificate of Registration but to no avail;

4. That I am executing this affidavit to support my request with the Bureau of

Internal Revenue (BIR) for the reissuance of a new BIR Certificate of
Registration and for whatever legal purpose it may serve.

IN WITNESS WHEREOF, I have hereunto set my signature this __ day of _____,

2018 at Cabanatuan City.

LEAH RIVERA JACOBE

Affiant
ID No: ________________
Issued by: _____________

SUBSCRIBED AND SWORN to before me at the place and date above stated. I
hereby certify that I personally examined the affiant and am convinced that she
voluntarily executed the foregoing affidavit, read the same and understood its contents.

WITNESS MY HAND AND NOTARIAL SEAL.

Doc. No.: __;

Page No. __;
Book No. __;
Series of 2018;