Republic of the Philippines)

Province of Southern Leyte) S. S.

City of Maasin...............)

AFFIDAVIT OF LOSS

I, JOVEE M. SAN JUAN., of legal age, Filipino, single and a resident of Dolho, Bato,
Leyte, 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;

2. Sometime in November 2015, my purse was stolen along with my driver’s license and
other valuables;

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 ___________, at Maasin City,
Southern Leyte, Philippines.

JOVEE M. SAN JUAN

Affiant

SUBCRIBED AND SWORN TO before me this ________________ in Maasin City, Southern

Leyte, Philippines.

Doc. No. _____;

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