REPUBLIC OF THE PHILIPPINES )

PROVINCE OF PAMPANGA )S.S.

MUNICIPALITY OF GUAGUA )

AFFIDAVIT OF LOSS

I, XXXXXXXXXXXXXXXXXXXX, of legal age, Filipino, married, with residence at

Rizal, Guagua, Pampanga after having been duly sworn to in accordance with law,
hereby depose and say, that:

1. I am the lawful owner of a Driver’s LicenseReceipt issued by the Land

Transportation Office in San Fernando, Pampanga sometime in September
2017;

2. Said receipt was always kept in my wallet;

3. Sometime in September 2018, I was a victim of pick pocketing in Malolos,

Bulacanand I lost my wallet containing the said receipt;

4. Despite diligent efforts exerted by me to locate the same, all proved in vain, thus,
I now consider it as lost for all intents and purposes.

5. I have executed this affidavit to attest to the truth of the foregoing and to serve as
a supporting document for my application for the issuance of a drivers license
and for any other legal purpose(s) it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this 2nd day of

October2018 in Guagua,Pampanga, Philippines.

XXXXXXXXXXXXXX
Affiant

SUBSCRIBED AND SWORN to before me this 2nd day of October 2018, in

Guagua, Pampanga Philippines, by xxxxxxxxxxxxxxx whose identity has been
satisfactorily proven to me through Noel Gorobat exhibiting to me his AFP id card with
no. xxxxxxxxxxxxxxxx and xxxxxxxxxxx exhibiting his Police Clearance Id Card
xxxxxxxxxxxxxxxxxx6 who personally know the affiant as the same person who
executed and personally signed before me this affidavit.

WITNESS MY HAND AND SEAL OF OUR OFFICE.

CONTROL No.
xxxxxxxxxxxxxxxxxx
Public Attorney II
(Pursuant to R.A. No. 9406)