Affidavit of Loss - ATP

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REPUBLIC OF THE PHILIPPINES)

___________________________) S.S.

AFFIDAVIT OF LOSS

I, ERNESTO C. PALOMIQUE III, Corporate Secretary of DETOXICARE


PHILS, INC. Filipino, married, with residence at_________________________________, after
having been sworn to in accordance with law hereby depose and say that:

1. I am the duly corporate secretary of DETOXICARE PHILS, INC. located at


606 Richmonde Plaza, Brgy. San Antonio, Pasig City;

2. That the said business had been duly registered with the Bureau of Internal
Revenue last

3. As such, I am the document custodian of the BIR Form No. 1921 Authority
to Print;

4. That despite diligent search and effort to locate the BIR Form No. 1921
Authority, I could not find the same such that I believe that it is now lost
beyond recovery;

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


Internal Revenue (BIR) for the reissuance of Authority to Print and for
whatever legal purpose it may serve.

IN WITNESS WHEREOF, I have hereunto signed my name this ____ day of


October 2021 in______________________, Philippines.

ERNESTO C. PALOMIQUE
Affiant

      SUBSCRIBED AND SWORN to before me this _____ day of October 2021


in Quezon City Philippines. Affiant exhibited to me his competent evidence of
identity consisting of TIN 405-94-008 issued at______________on __________________.

Notary Public

Doc. No____;
Page No. ___;
Book No. ___;
Series of 2021

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