AFFIDAVIT OF LOSS

I, __________________________________________________ (full name),

single/married/widow/widower, Filipino, of legal age, and a resident
of _____________________________________________, after having been duly
sworn in accordance with law, hereby depose and say:

1. That I am a registered non-professional driver with the Land Transportation

Office (LTO) as evidenced by the Provisional Non-Professional Driver’s License
No. N04-10-004450 issued last 08 August 2018 (with Official Receipt No.
1338950082);

2. That I used to put said Provisional Non-Professional Driver’s License, together

with the my other government issued identification cards, in my filing cabinet,
among others;

3. That sometime on 01 October 2018, when I arrived home, I discovered that said
Provisional Non-Professional Driver’s License could no longer be found in my
filing cabinet where I used to place it;

4. That diligent effort to locate the said Provisional Non-Professional Driver’s

License had proved futile;

5. That I am executing this affidavit to attest to the truth of the foregoing facts and to
request for a replacement plastic license card or any substitute document from
the LTO.

IN WITNESS WHEREOF, I have hereunto affixed my signature this 15TH day of

October 2018 in the City of Manila, Philippines.

MARIEL INMENZO DUCOG

    
SUBSCRIBED AND SWORN TO before me, a notary public in and for the City of
Manila this 15th day of October 2018. The affiant, whom I identified through the
following competent evidence of identity: UMID Card No. CRN 0033-8560555-
4 issued by the Social Security System (SSS), personally signed the foregoing
instrument before me and avowed under penalty of law to the whole truth of the
contents of said instrument.

Notary Public                      
Doc. No. ........;
Page No. .......;
Book No. .......;
Series of 2018.