REPUBLIC OF THE PHILIPPINES....

)
Province of Davao del Norte..............) S.S.
City of Tagum....................................)

AFFIDAVIT OF LOSS

I, MARX ISRAEL L. LORONO , Filipino, of legal age, and a resident

of_________________________________ , Philippines after having been duly
sworn to in accordance with the law, do hereby depose and say THAT;

1. That I am a driver of a XRM 110 motor vehicle owned by the Provincial

Government of Compostela Valley bearing the plate number SF 2896;

2. Sometime on October 19, 2018 , said temporary driver's license was misplaced
and got lost;

3. Efforts were exerted to locate said temporary driver's license, but in spite of
diligent search, it could not be found and the same is now beyond recovery;

4. I am executing this Affidavit to attest to the truth and veracity of the foregoing
statements and to apprise the proper authorities concerned on the matter for
their information, guidance and for whatever legal purpose/s this may serve
best.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ______ day

of ______________ at ___________________________, Philippines.

VICENTITO A. JARA
Affiant
ID No. :_______________

SUBSCRIBED AND SWORN TO BEFORE ME this ________ day of _________

in __________________, with affiant exhibited to me his above indicated competent
evidence of identity.

Doc. No. _______

Page No. _______
Book No. _______
Series of _______