REPUBLIC OF THE PHILIPPINES )

PROVINCE OF ) S.S.

X-------------------------

AFFIDAVIT OF LOSS

I, __________________, of legal age, Filipino, married, and a resident

of____________________, Philippines, after having been duly sworn in accordance with
law, hereby depose and state:

1. That I am a holder of a PROFESSIONAL DRIVER’S LICENSE issued by the

Land Transportation Office;

2. That on April 18, 2017 at around 1:00 o’ clock in the afternoon, while I was
traveling from ____________ heading to_________________, I lost my
wallet containing my PROFESSIONAL DRIVER’S LICENSE and other
documents;

3. That I exerted efforts to retrieve my PROFESSIONAL DRIVER’S LICENSE

through checking my belongings and going back to the places I have been
to that day, but it proved to be fruitless;

4. That I lost my PROFESSIONAL DRIVER’S LICENSE through accident and

with the exercise of diligence of a reasonable and prudent person exercising
care over her things and circumstances;

5. That I am executing this affidavit in order to attest to the veracity of the

foregoing facts and for whatever legal purpose this may serve;

IN WITNESS WHEREOF, I have hereunto set my hand this _______________

at _________________, Philippines.

JESSIE D. LARAÑO
Affiant

SUBSCRIBED AND SWORN to before me, this _______________ by affiant who

exhibited to me his TIN No. ____________ issued at ________________, Philippines as
his Competent Evidence of Identity (CEI) in accordance with the 2004 Rules on Notarial
Practice. I HEREBY CERTIFY THAT HE UNDERSTOOD THE CONTENTS OF THIS
AFFIDAVIT AND THAT THE SAME IS TRUE AND CORRECT ACCORDING TO HIS OWN
KNOWLEDGE AND BASED ON AUTHENTIC RECORDS.

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 2017.