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REPUBLIC OF THE PHILIPPINES)

PROVINCE OF SULTAN KUDARAT) S.S.


MUNICIPALITY OF ISULAN)
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AFFIDAVIT OF LOSS

I, LOPEZ Y TEOFILO DIENTE JR, of legal age, Filipino, married and a resident of Purok
Katilingban,Bagumbayan, Sultan Kudarat, after having been duly sworn to in accordance with law do
hereby depose and say:

1. That I am the above-named person and a holder of the following;

PROFESSIONAL DRIVERS LICENSE issued by Land Transportation Office


(LTO)
TAX IDENTIFICATION CARD issued by Bureau of Internal Revenue
SENIOR CITIZEN IDENTIFICATION CARD
VOTERS IDENTIFICATION CARD issued by Commission on Election
(COMELEC)
CERTIFICATE OF REGISTRATION (CR) AND OFFICIAL RECEIPT (OR)
issued by Land Transportation Office (LTO);

MAKE/TYPE OF BODY--------------------KAWASAKI/MC
Serial/Chassis No: -----------------------------DUZWCJ33998
Engine No: --------------------------------------MD2A18AZ6CJ35895
PLATE NO. ------------------------------------XZ1377
COLOR: ----------------------------------------BLACK

2. That sometime on November 20, 2017 I discovered that said Identification Cards were lost
or misplaced by me;

3. That I diligently searched and look for the said Identification cards but I could no longer
locate the same;

4. That I execute this affidavit to establish and declare the fact of the foregoing statements and
for whatever purpose this affidavit may serve best.

IN WITNESS WHEREOF, I have hereunto set my hand this 23rd day of November, 2017 at Isulan,
Sultan Kudarat, Philippines.

LOPEZ Y TEOFILO DIENTE JR


Affiant

SUBSCRIBED AND SWORN to before me this 23rd day of November, 2017 at Isulan, Sultan
Kudarat, Philippines.

ATTY. KYNDELL A. HILARIO, CPA


Notary Public until December 31, 2018
Doc. No.187 For the Province of Sultan Kudarat
Page No. 39 RTC Isulan order MISC CASE NO. 294
Book No.23 ROLL NO. 61861/4-25-13
Series of 2017. TIN: 258-815-395
PTR NO. 2589412/01-03-17/ISK
IBP. NO. 952291/11-10-2016/ISK
MCLE NO. V-0016438-3-29-16
Address: Kalawag II, Isulan, Sultan Kudarat

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