Republic of the Philippines)

Province of Masbate ) S.S.

City of Masbate )

AFFIDAVIT OF LOSS

I, Remegio S. Beruya, of legal age, Filipino and a resident of Brgy.

Poblacion, Balud, Masbate , after having been duly sworn to in accordance
with law, hereby depose and say:

1. That I was issued a receipt when my temporary professional driver’s

license was issued by the Land Transportation Office ( LTO);

2. That recently, I noticed that my license receipt was missing, efforts to

locate in vain, and for all intents and purposes considered lost or
stolen;

3. That I wish to manifest that said driver’s license receipt was not given
or endorsed to anybody but simply lost or stolen;

4. That I have executed this affidavit to attest to the truth of all the
foregoing and satisfy the inquiry or requirements of any person or
office particularly the LTO and for other legal purpose.

IN WITNESS WHEREOF, I have hereunto set my hands this 18th.DAY OF

JNAUARY 2018 in the City of Masbate, Philippines.

Remegio S. Beruya
Affiant

JURAT

SUBSCRIBED AND SWORN to before me this _______________ at Masbate

City AFFIANT exhibiting to me as proof of his identity his temporary driver’s
license with no. EO3-09-001145.

Doc. No. _______;

Page No. _______;
Book No. III;
Series of 2018;