Republic of the Philippines )

City of ___________ ) S.S.

AFFIDAVIT OF CANCELLATION

I, _________, of legal age, Filipino citizen, and a resident of __________,

after having sworn to in accordance with law, hereby depose and state that:

1. I am the registered owner of a business under the trade name ______

located at ___________;

2. The above mentioned business was duly registered at the Department of

Trade and Industry (DTI) on _________ with Certificate of Registration
No. ________;

3. At present, I am causing the cancellation of the above mentioned business

name due to ___________;

4. As far as my personal knowledge as the registered owner, I confirm that

__________ has no standing financial obligation to any individual, public
or private corporation or entities;

5. I am executing this Affidavit to attest to the truthfulness of the foregoing

declarations under penalties of perjury and to respectfully request the DTI to
CANCEL Certificate of Registration No. _______, moreover, to serve
all legal intents.

FURTHER AFFIANT SAYETH NAUGHT.

IN WITNESS WHEREOF, I hereby affix my signature on this ___ day of

_______ 2017 at _________.

_____________
Affiant

SUBSCRIBED AND SWORN TO BEFORE ME on this ___ day of _____

2017 at _______. Affiant exhibiting to his _______ with _______, bearing his
photograph and signature and avowed the truthfulness of the foregoing declarations.

NOTARY PUBLIC

Doc. No.: ____

Page No.: ____
Book No.: ____
Series of _____.