REPUBLIC OF THE PHILIPPINES)

CITY OF SAN CARLOS, PANGASINAN)) S.S.

AFFIDAVIT OF LOSS

I, NESTOR F. RAMOS, of legal age, married, Filipino citizen, and with residence
address at Brgy. Poblacion, Basista, Pangasinan after being duly sworn in accordance with
law, depose and state that:

1. I am a holder of an Official Receipt of my Driver’s License issued by the Land

Transportation Office at San Carlos City, Pangasinan;

2. On May 08, 2023, at around 9:00 P.M, while I was on my way home, I discovered
that my wallet containing the said Official Receipt was lost;

3. Despite the diligent effort to locate said lost receipt, the same proved to be futile up to
the present and presumed to be lost and beyond and recovery; and

4. I am executing this affidavit to declare the truth of the above facts and to be
substantiate the loss of the said receipt for whatever legal purposes it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this____________ in San

Carlos City, Pangasinan, Philippines.
_________________
NESTOR F. RAMOS
Affiant
LTO Driver’s ID no.: A12-91-000245

  SUBSCRIBED AND SWORN TO before me this _____________________ in San

Carlos City, Pangasinan, Philippines.