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REPUBLIC OF THE PHILIPPINES) Province of ____________________) S.S.

City/Municipality of _____________) x-----------------------x

I, _____________, Filipino, of legal age, married, and a resident of _____________, Philippines, after being duly sworn to in accordance with law, hereby depose and state: 1. That I am an employee of _____________ at _____________, Philippines and at the same time a duly-licensed driver; 2. That on _____________ at around ________, while I was at the _____________ at _____________, I lost my wallet which I usually place inside__________; 3. That inside the said wallet are my Driver's License and ATM Cards issued by _____________ Bank, _____________ Branch; 4. That despite diligent search and efforts to locate the said wallet and my Driver's License and my ATM Card, and _____________s, I could not find them such that I now believe that they are now lost beyond recovery; 5. That my Driver's License has not been confiscated by the LTO, Police or other Traffic Enforcers for any traffic violation; 6. As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing and to support my application for the issuance of a new Driver's License and a new ATM Card, in lieu of the ones that were lost. IN WITNESS WHEREOF, I have hereunto set my hand this _____________ at _____________, Philippines. AFFIANT

SUBSCRIBED AND SWORN to before me, this _____________, by the Affiant who is personally known to me (or whom I have identified through competent evidence of identity) and who exhibited his/her Community Tax Certificate No. _____________ issued at _____________ on _____________. or Identification Card No. ____ issued by ______ with expiry on ________.

NOTARY PUBLIC Doc. No. ______; Page No. ______; Book No.______; Series of 2011.