AFFIDAVIT OF LOSS

I, SAMUEL C. GREGORIO, of legal age, Filipino and a resident of Blk. 20 Lot 21,
Mangga III Kasoy St. Nagpayong, Brgy. Pinagbuhatan, Pasig City, Metro Manila,
Philippines, after having been duly sworn in accordance with law, hereby depose and state
that:

1. I am a licensed driver under the law of the Republic of the Philippines;

2. That on 2 December 2019 around 3:00 in the afternoon while I was at Pasig Market in
Pasig City, my driver’s license was lost;

3. Despite diligent search and efforts to locate my driver’s licensed, I could not find the
same;

4. I am therefore executing this affidavit to attest to the truth of the foregoing facts, for
the reissuance of driver’s licensed, and for whatever legal purpose this may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this _____________ at

Pasig City, Philippines.

SAMUEL C. GREGORIO
Affiant

SUBSCRIBED AND SWORN to before me this 4th day of December 2019 at Pasig
City, affiant exhibited to me the following:

Name Valid ID Date/Place Issued

Samuel C. Gregorio

Doc. No. : ________;

Page No. : ________;
Book No. : ________;
Series of 2019