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REPUBLIC OF THE PHILIPPINES)

CITY OF MANDALUYONG) S.S.


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

AFFIDAVIT OF LOSS
I,
Marc
Laurenze
C.
Celis,
of legal age,
Filipino,
(single/married/widow) and a resident of 9-1 Don Vicente St., Villa
Dolores Subd., Angeles 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 C10-11022717 which is valid until 2017-05-02.
2. Sometime on December 7, 2016, The LTO Official Receipt of said
driver's license was misplaced and got lost;
3. Efforts were exerted to locate said LTO Official Receipt, but in spite of
diligent search, it could not be found and the same is now beyond
recovery;
4. Said LTO Official Receipt 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
duplicate copy of the LTO Official Receipt and the use of this affidavit
as requirement for insurance claim, in lieu of the one that was lost;
IN WITNESS WHEREOF, I have hereunto set my hand
this ___________________ in
Makati
City,
Metro
Manila, Philippines.
Marc Laurenze C. Celis
Affiant
Passport No. EC3189320

SUBCRIBED
AND
SWORN
TO before
me
this ___________________ in
_________________, Philippines,
affiant exhibiting to me his/her competent evidence of identity by way
of
__________________
issued
at
______________
on __________________.
Doc. No. _____;
Page No. _____;

Book No. _____;


Series of 2016.