REPUBLIC OF THE PHILIPPINES )

CITY OF MANDAUE ) S.c.

AFFIDAVIT OF LOSS
I, ATLANO GARCES PARAY JR., of legal age, married, Filipino
and a residen of !ig"#a$ %ag&i'a$, %anda&e Ci$, Ce(&, afer (eing
s#orn o in a))ordan)e #i" la#, depose and sa$ "a*
+. I #as pre,io&sl$ iss&ed a dri,er-s li)ense.
/. I &sed o 'eep "e a(o,e0menioned e,iden)e of ideni$ in m$
#alle.
1. A(o& a #ee' ago, #"ile I #as on m$ #a$ o m$ #or'pla)e, I
a))idenall$ lef m$ #alle or mispla)ed i.
2. I ried all effors o lo)ae "e mispla)ed #alle oge"er #i" is
)onens (& I #as no a(le o find i.
3. T"e dri,er-s li)ense is no# (e$ond re)o,er$. and
4. I am e5e)&ing "is s#orn saemen, as re6&ired, o ena(le me
o o(ain a repla)emen for "e said los do)&men.
IN 7ITNESS 7!EREOF, I "a,e "ere&no se m$ "and "is 888 da$
of %a$ /9+2, in "e Ci$ of %anda&e, P"ilippines.
ATILANO G. PARAY JR.
Affiant
JURAT
S:;SCRI;E< and s#orn o (efore me, "is +1
"
da$ of %a$ /9+2, in
"e Ci$ of %anda&e, Ailano G. Para$ Jr. personall$ 'no#n o "e
&ndersigned and "e former e5"i(iing o "e laer "is Comm&ni$ Ta5
Cerifi)ae #i" No. CCI/9+19=2+=>91 iss&ed in "e Ci$ of %anda&e for
"e $ear /9+2.
<o). No. 888.
Page No. 888.
;oo' No. 888.
Series of /9+2.
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