REPUBLIC OF THE PHILIPPINES) S.S.

PASIG CITY )

AFFIDAVIT OF LOSS

I, TAYLOR MARIE BATUNGBAKAL, Filipino, of legal age and a resident of 1213 Cornelia
St., Brgy. Sapang Palo, Cainta, Rizal, after being duly sworn in accordance with law, hereby
depose and state that:

1. I was issued a Driver’s License with DL No. CXX-XXXXXXXXXXXX by the Land

Transportation Office last 13 December 2021;

2. I usually keep my Driver’s License in my possession by storing it in my wallet;

3. On 3 July 2022, while I was walking home, my wallet was stolen together with all my
personal belongings therein, including my Driver’s License;

5. The said Driver’s License has not been confiscated by any officer of the law or the
issuing office or agency due to the violation of any law, statute, order, rule or
regulation;

6. In the event that the lost Driver’s License should hereafter be found or located, I
undertake to forward or surrender the same to the Land Transportation Office for
appropriate disposal;

7. I am executing this Affidavit of Loss to attest to the truth of the foregoing and in
support of our request for the replacement of the said check, and for whatever legal
purpose it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this 6th day of July 2022 at Pasig
City, Philippines.

(Sgd)
TAYLOR MARIE BATUNGBAKAL
Affiant

SUBSCRIBED AND SWORN to before me, this 7th day of July 2022 in the City of
Pasig, with affiant exhibiting her Unified Multipurpose ID with No.
CRNXXXXXXXXXXXXXXXXXX, issued on 12 December 2020.

Doc. No. : 65;

Page No. : 20;
Book No. : XX;
Series of 2022.