REPUBLIC OF THE PHILIPPINES)

CITY OF MAKATI ) S.S.

x--------------------------------------x

AFFIDAVIT OF LOSS

I, Ma. Clarissa Mendiola, of legal age, Filipino, single and a resident of

Unit 4021 Jazz Residences N. Garcia cor Jupiter Streets, Makati City, after
having been duly sworn to in accordance with law, depose and state THAT:

1. I am a duly-licensed driver in accordance with pertinent Land Transportation

laws, rules and regulations, and was issued a corresponding
(Non) Professional Driver's License with number D08-003985 which is valid
until November 18, 2018;

2. Sometime on January 9, 2018, said driver's license was misplaced and got
lost;

3. Efforts were exerted to locate said driver's license, but in spite

of diligent search, it could not be found and the same is now beyond
recovery;

4. Said Driver's License has not been confiscated by the LTO, Police or other
Traffic Enforcers for any traffic violation;

5. As such, I am executing this Affidavit of Loss to attest to the truth of the

foregoing and to support my application for the issuance of a new
(Non) Professional Driver's License, in lieu of the one that was lost;

IN WITNESS WHEREOF, I have hereunto set my hand this 28th day

of January 2018 in Makati City, Metro Manila, Philippines.

Ma. Clarissa Mendiola

Affiant

SUBCRIBED AND SWORN TO before me this 29th day of January

2018 in Manila, Philippines, affiant exhibiting to me her competent evidence
of identity by way of Senate ID No. 2010-4686 issued at Pasay City
on September 2013.

Notary Public

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 2018.