REPUBLIC OF THE PHILIPPINES )

PROVINCE OF CAMARINES NORTE ) SS.

MUNICIPALITY OF DAET )

AFFIDAVIT OF LOSS

I, abcdefg, of legal age, Filipino citizen, married, and with residence and
postal address at Bella Maria Village, Daet, Camarines Norte, after having been
duly sworn to in accordance with law, hereby depose and say:

That I was the holder of the following license, ID, and other documents, to
wit:
1. Professional Drivers License issued by the Land Transportation Office
(LTO);
2. SSS Member ID issued by the Social Security System
3. CANORECO Official Receipt (OR) for the payment of electric bill for the
month of May, 2017

That said license, ID, and other documents were placed inside my wallet
which I always kept in my possession as might be needed for identification
purposes in my transactions and likewise as to my driver license, as required by
law to be in possession whenever I was driving my motor vehicle;

That however, sometime around 8:45 p.m. of June 7, 2017, shortly after
arriving home, I checked the pockets in my jacket to get my wallet, but I noticed
that it was already missing;

That utmost efforts were exerted in trying to find said wallet containing my
drivers license, SSS ID, CANORECO OR, with cash amounting to Php1,000.00, but
to no avail, and now the same are considered lost and beyond recovery;

That said license was not confiscated by the PNP/LTO or any deputized law
enforcement personnel for any traffic/driving violation, but the wallet containing
said lost items in all likelihood unknowingly slipped off the pocket of my jacket
while I was on my way home that night;

That I am executing this affidavit to attest to the loss of the above-listed

items, in support for my application for their replacement particularly my driver
license and SSS ID, and for whatever legal purpose this may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this 8th day of June,
2017, in Daet, Camarines Norte.

abcdefg
Affiant

SUBSCRIBED AND SWORN to before me this 8th day of June, 2017, in

Daet, Camarines Norte, by the above-named affiant who presented to me his BIR
TIN Card No. 123-456-626.

Doc. No. ____

Page No. ____
Book No. 4
Series of 2017.