Republic of the Philippines ]

Province of Bohol ]
Municipality of Carmen ] S.S.

AFFIDAVIT OF LOSS
(Re: Driver’s License and Official Receipt)

I, LYDIA L. VERADOR, Filipino, of legal age, single and a resident of Purok 2

Catagda-an, Pilar, Bohol, Philippines, after being duly sworn in accordance with law, hereby
depose and say:

1. That I am a holder of a Non-Professional Driver’s License duly issued by the Land

Transportation Office (LTO) and an Official Receipt of a certain motorized vehicle
specifically described as follows:

Make: Mitsubishi
Body Type: Wagon
Plate No.: GPN353
Engine No.: 4D56A-MO193
Chasis No.: PAEVB5WLN1B005369
C.R. No. (2009): 8452388-0

2. That said Non-Professional Driver’s License and Official Receipt got lost last January
5, 2023;

3. That I exerted diligent efforts to find and recover the aforesaid Non-Professional
Driver’s License and Official Receipt, however, my efforts proved futile as until now,
its whereabouts still could not be ascertained, hence, I considered it to be lost for all
intents and purposes;

4. That the said Non-Professional Driver’s License and Official Receipt was not
transferred to any person for consideration or used as collateral to secure obligations;

5. That I execute this affidavit voluntarily to attest to the truth of the foregoing
statements to support my request for the issuance of another Non-Professional
Driver’s License and Official Receipt in lieu of the lost one;

6. That further, I execute this affidavit for whatever legal purpose this may serve.

IN WITNESS WHEREOF, I hereunto set my hand this 14 th day of March, 2023 at

Carmen, Bohol, Philippines.

LYDIA L. VERADOR
Affiant
National ID No. 2983-9735-1827-4961
Issued by the Philippine Statistics Authority (PSA)

SUBSCRIBED AND SWORN TO before me this 14th day of March, 2023 at Carmen,
Bohol, Philippines.