REPUBLIC OF THE PHILIPPINES )

CITY OF SAN FERNANDO ) S.S.

AFFIDAVIT OF LOSS

I, ___________________, legal age, married, Filipino and a resident of

_______________ __________________________, under oath, depose and state that:

1. I am a holder of Non-Professional Driver’s License No. C10-95-115322,

BDO ATM Debit Card, and TIN identification card;

2. I customarily placed my said identification cards, including my BDO

Debit card in my wallet ;

3. However, on May 20, 2019 I noticed that my wallet was missing,

containing, among others, my LTO Driver’s License, BDO ATM Debit
card, and TIN card;

4. I exerted earnest efforts to find my missing wallet, but in spite of diligent

search it can no longer be found;

5. That my wallet, including my LTO Driver’s license, BDO Debit card and
TIN identification card are beyond recovery;

6. I execute this affidavit to attest to the truth of the foregoing statements

and to request the agencies concerned for the replacement of lost
cards.

IN WITNESS WHEREOF, I have hereunto set my hand and affixed my

signature this 28th day of May 2019 in the City of San Fernando, Pampanga.

______________________
Affiant

SUBSCRIBED AND SWORN to before me this 28TH day of May 2019 in the
City of San Fernando, Pampanga and within the jurisdiction of the
Commissioning Court, ROBERTO F. GUTIERRZ has satisfactory proven to me his
identity thru his _______________________.

Doc. No.
Page No.
Book No.
Series of 2019