Republic of the Philippines )

Camiling, Tarlac ) S.S.

AFFIDAVIT OF LOSS
I, MAXIMO ESTRADA LIBRES, 29 years old, Filipino citizen, single and a
resident of Barangay Torre 2nd, Mangatarem, Pangasinan, Philippines, after having
been duly sworn to in accordance with law, do hereby depose and state THAT:

1. In the afternoon of June 11, 2017, upon reaching home on board my

motorcycle, I noticed that my wallet, which I earlier placed at the back
pocket of my pants, was missing. My wallet contained my Professional
Drivers License Card, some cash and other personal belongings;

2. I then checked the other pockets of my pants but I did not find my wallet. I
also went back along the way to search for it but I still found nothing.
Moreover, I asked the people I met along the way if they have seen or
found my missing wallet but they all answered in the negative;

3. The incident was reported to the Mangatarem Police Station,

Mangatarem, Pangasinan;

4. All my diligent efforts to locate my missing wallet and its contents proved
futile; hence, I now consider them as lost and beyond recovery;

5. My professional drivers license card was never confiscated by any

authority or used as a security to any obligation or transaction;

6. I am executing this affidavit to attest to the truth of the foregoing

statements and for whatever legal purposes and intents this may serve.

IN WITNESS WHEREOF, I have hereunto affixed my signature this 28th day

of June, 2017 at Camiling, Tarlac, Philippines.

MAXIMO E. LIBRES
Affiant

SUBSCRIBED AND SWORN to before me on the date and place indicated

above. Affiant exhibited to me his Police Clearance with No. 2017-06-175 issued by
the Mangatarem Police Station, Mangatarem, Pangasinan on June 14, 2017.

Doc. No.:________;
Page No.:_______;
Book No.:_______;
Series of 2017.