REPUBLIC OF THE PHILIPPINES )

CITY OF _____________________ )S.S.

AFFIDAVIT OF LOSS

I, ___________________________________, Filipino, of Legal Age, with residential address

at _____________________________________, Philippines, after having been duly sworn in
accordance with law, hereby depose and state that:

1. I am the lawful owner of a Philippine Driver’s License with Driver’s

License No. D04-123-123, which was placed in my wallet;

2. Sometime on January 10, 2018, as I was disembarking from my vehicle

upon arriving home in my above mentioned address, I was surprised to
discover that my wallet was no longer among my belongings or on my
person;

3. Despite diligent efforts exerted to find the said wallet, the same could no
longer be found and the same, along with the contents thereof, are truly
lost and unrecoverable; and

4. I am executing this affidavit to attest to the truth of the foregoing facts,

to aid in the replacement of my lost Philippine Driver’s License with
License No. D04-123-123, and for whatever legal purpose the same may
serve.

FURTHER AFFIANT SAYETH NAUGHT

IN WITNESS WHEREOF, I hereby set my hand this January 29, 2018, in

______________________ City, Philippines.

<NAME OF AFFIANT>
Affiant

SUBSCRIBED AND SWORN TO before me this January 29, 2018, in the City of
_______________________, Philippines, herein affiant personally appeared and exhibited to me
his TIN ID No. 009-035-143 as competent proof of his identity.

NOTARY PUBLIC

Doc No. ______;

Page No. ______;
Book No. ______;
Series of 2018