REPUBLIC OF THE PHILIPPINES)

Province of Camarines Sur) S.S.

City of Naga)
x - - - - - - - - - - - - - - - - - - - - - - - x


AFFIDAVIT OF LOSS

I, EULALIO C. TEOXON, Filipino, of legal age, married, and a resident
of New Poblacion, Cabusao, Camarines Sur, after being duly sworn to in
accordance with law, hereby depose and state:


1. That on March 14, 2014 at around nine o clock in the morning (9:00
a.m.), while I was riding my motorcycle within the barangay of New
Poblacion, Cabusao, Camarines Sur, I lost my wallet which I usually
place in my back pocket;

2. That inside the said wallet are my Driver's License Card and receipt,
Community Tax Certificate, SSS ID Card, Voters ID Card and other
important documents;

3. That despite diligent search and efforts to locate the said wallet, I
could not find them such that I now believe that they are now lost
beyond recovery;

4. That my Driver's License has not been confiscated by the LTO, Police
or other Traffic Enforcers for any traffic violation;

5. As such, I am executing this Affidavit of Loss to attest to the truth of
the foregoing and to support my application for the issuance of a new
Driver's License and for other lawful purposes.

IN WITNESS WHEREOF, I have hereunto set my hand this
_____________ at _____________, Philippines.

EULALIO C. TEOXON
AFFIANT


SUBSCRIBED AND SWORN to before me, this _____________, by the
Affiant who is personally known to me at Naga City, Philippines.





NOTARY PUBLIC

Doc. No. ______;
Page No. ______;
Book No.______;
Series of 20____.