Republic of the Philippines )

City of Ormoc ) S.S.

AFFIDAVIT OF LOSS

I, ELISARIE O. AMANCIO, JR., of legal age, Filipino, single and with

residence at Brgy. Cogon, Ormoc City, Leyte, after having been sworn to oath in
accordance with law, hereby depose and state:

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

Land Transportation laws, rules and regulations, and was issued
a corresponding Driver's License with number H0316000792
which is valid until the year 2019;

2. That sometime last week, when I arrived home from work, I

discovered that my wallet where said Driver's License and all my
other Identification Cards got lost;

3. That despite diligent search and efforts to locate my Driver's

License, I could not find the same such that I now believe that it
is now lost beyond recovery;

4. That 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 Driver's License, in lieu of the one that was
lost.

IN WITNESS WHEREOF, I have hereunto affixed my signature this __ day

of May 2017 at Ormoc City, Leyte.

ELISARIE O. AMANCIO, JR
Affiant

Subscribed and sworn to before me this 15th day of May 2017 at Ormoc
City, Leyte. Affiant exhibiting to me his
_____________________________________________________ as competent proof of
his identity.

Doc. No. _____;

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