REPUBLIC OF THE PHILIPPINES )

QUEZON CITY ) S.S.

AFFIDAVIT OF LOSS

I, __________, Filipino, of legal age, presently residing at _________, after having been
sworn to in accordance with law hereby depose and state:

1. Last December 2014, I applied for a reneweal of my Drivers License with the
Land Transportation Office (LTO). Consequent to the said application for
renewal, I was issued Official Receipt by the LTO which I will use to claim my
License when it is released by April 2015 per LTOs instruction.

2. Last 09 April 2015, I went to the gym and remember leaving my wallet in my gym
bag which in turn i placed inside my locker. Inside my wallet was the
abovementioned Official Receipt issued by the LTO;

2. When I got home after my gym session, i was looking for my wallet and could no
longer find it in my gym bag;

3. After exerting all effort in trying to locate my wallet as well as the LTO Official
Receipt, I stil could not my the said items and I now consider them lost and
beyond recovery; and,

4. That I am executing this affidavit to certify the loss of the LTO Official Receipt.

AFFIANT FURTHER SAYETH NAUGHT.

IN WITNESS WHEREOF, I have hereunto set my hand this 6th day of May 2015 at Quezon
City.

_____________________
Affiant

SUBSCRIBED AND SWORN to before me, this __ day of July 2016 at Quezon City, with
affiant exhibiting his ____________ on as competent proof of his identity, and affiant attesting to
me that this Affidavit of Loss, consisting of one (1) page including this page on which this
acknowledgement is written, is his true act and deed freely and voluntarily given.

Doc. No. 434

Page No. 88
Book No.II
Series of 2015