REPUBLIC OF THE PHILIPPINES )

S.S.
CITY OF MANILA )
x-----------------------------------------------------------x

AFFIDAVIT OF LOSS

I, KENT CELESTE BOLLER, of legal age, Filipino, single and a resident of #615
Reyes Drive, Baesa, Caloocan City, after having been duly sworn to in accordance with
law, depose and state THAT:

1. I am the holder of Drivers License No. NO2-14-013-9063;

2. On 23 February 2016, while driving my motorcycle on my way home, my

wallet together with my Drivers License inside, fell on my pocket. I had
tried to look for my wallet but the same could not be found;

3. Despite diligent search and efforts to locate the said wallet, I could not find
the same such that I believe that it is now lost beyond recovery;

4. As such, I am executing this affidavit to attest to the foregoing facts and to

support the application for the issuance of a new one in lieu of the one
which was lost.

IN WITNESS WHEREOF, I have hereunto set my hand this ____________ day

of February 2016 in Quezon City, Philippines.

KENT C. BOLLER
Affiant

SUBCRIBED AND SWORN TO before me this ______________ day of

February 2016 in Quezon City, Philippines, affiant exhibiting to me his NHA ID No.
527411

NOTARY PUBLIC
Doc. No. _____
Page No. _____
Book No. _____
Series of 2016.