Republic of the Philippines

______________________ City) S.S

AFFIDAVIT OF LOSS
I, ERNEST G. REGENCIA, Filipino, of legal age, and residing at No. 19-F
Domingo M. Gueverra Street, Brgy, Highway Hills, Mandaluyong City 1550, after
having first duly sworn in accordance with law, hereby depose and state as
follows:
1. I am the owner of a Drivers Licence NDOS-15398 issued by Land
Transportation Office (LTO) Shaw Boulevard, Mandaluyong City on
November 2010;
2. On August 1, 2016 at around 6:00in the evening, I was riding on a taxi cab
going to our house in Mandaluyong. As I reach our house and after I had
alighted therefrom, I realized that my wallet containing my said drivers
license was missing. It was too late for me to realize that it fell from my
pocket inside that said taxi cab which had already left away;
3. I likewise fail to notice the name of the taxi unit and its plate number;
4. I am therefore executing this affidavit to report the loss of my Drivers
License and to request for the replacement thereof.
IN WITNESS WHEREOF, I have hereunto voluntarily affix my signature on this
_____ day of November, 2016, to attest to the truth of the foregoing.

ERNEST G. REGENCIA
Affiant
SSS ID No. 33-56732
--------------------------------------x
SUBSCRIBE AND SWORN to before me on this ____________ day of
November 2016 by the affiant who exhibited to me his foregoing competent proof
of identification.

Doc. No___
Page No. ___
Book No.___
Series 2016