REPUBLIC OF THE PHILIPPINES

CITY OF URDANETA } S.S.

AFFIDAVIT OF LOSS
I, NOR-ALEAH M. DAMIANO, of legal age, Filipino, single, and a resident of
Alexander St., Brgy. Poblacion, Urdaneta City, Pangasinan, after having sworn to in
accordance with law, hereby, depose and state that:

1. I am the holder of a Land Transportation Office (“LTO”)-issued Non-

Professional Driver’s License registered under my name and account;

2. Said Driver’s License was kept safe in my wallet;

3. On or about 9 March 2020, I was buying merienda from a sari-sari store Lipa,
Batangas, near the gate of the College where I was enrolled; thereafter, I noticed that my
wallet was missing;

4. I have exerted diligent efforts to locate the same but to no avail;

5. My Driver’s License was never confiscated, revoked, cancelled, or in any way

made ineffective due to violation of any law, rule or regulation;

6. As a requirement for the issuance of another Driver’s License in lieu of the lost
one, I am required to execute an affidavit of loss;

7. In compliance with the abovementioned requirement, I hereby execute this

affidavit to request the authorities concerned to issue me a new Driver’s License in lieu
of the lost one; and

8. I am executing this affidavit to attest to veracity of the foregoing facts and for
whatever legal purpose it may serve.

IN WITNESS WHEREOF, I hereunto affix my signature this 7 day of July 2020

in the City of Urdaneta.

_________________________
NOR-ALEAH M. DAMIANO
Affiant

___________________________ ___________________________
Witness Witness

SUBSCRIBED AND SWORN to before me on the date and place first above
written, affiant presenting to me, as competent proof of identity her TIN No. 498-632-
156 issued in the City of Urdaneta, Province of Pangasinan.

Doc No.: 447

Page No.: 91
Book No.: I
Series of 2020.