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Republic of the Philippines )

DONE: CITY OF BAGUIO ) SS.

AFFIDAVIT OF LOSS

I, EDWIN D. WILLIAM, of legal age, married, Filipino Citizen with residence and
postal address at Palansa, Bila, Bokod, Benguet after having been duly sworn to in
accordance with law do hereby depose and state that:

1. I was issued a Drivers License by the Land Transportation Office (LTO);

2. Sometime on July 2010, while walking along La Trinidads Trading post my


drivers license was placed inside my pocket wallet, however when I am
already at home, I checked my wallet but it was no longer in my pocket and I
suspect that it was snatched by a pickpocket;

3. I exerted diligent efforts to locate the snatcher of my wallet also contained my


said Drivers License but the same could no longer be found, hence,
considered forever lost;

4. The said Drivers License has not been given nor pledged to anyone for any
purpose whatsoever, nor was it taken or confiscated by the authorities for any
violation of any law or traffic law or regulations;

5. I am executing this affidavit to attest to the truth of my foregoing statements


and for purposes of securing new Drivers License in lieu of the lost one and
for all legal intents and purposes it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this 7th day of July 2016,
at Baguio City, Philippines.

EDWIN D. WILLIAM
Affiant

SUBSCRIBED AND SWORN TO before me this 7TH day of July 2016 at Baguio
City, Philippines. Affiant personally appeared before me and known to me personally
known to me to be the same person who executed this instrument freely and willingly.

MODESTO T. ANDONG
Notary Public
Commission No. 35-NC-16-R/Until: December 31, 2017
PTR No. 2426420/12-15-15/Baguio City
IBP No. 0980937/12-04-15/Baguio-Benguet Chapter
Roll No. 31289/5-15-81/Manila
MCLE COMPLIANCE No. V-0002709/July 3, 2014
BIR TIN No. 121-017-652
No. 13-B, 2nd Floor Old Market Bldg.,
Magsaysay Ave., Baguio City, Philippines
Doc. No. 230;
Page No. 46;
Book No. 18;
Series of 2016.