Republic of the Philippines)

Province of Masbate ) S.S.

City of Masbate )

AFFIDAVIT OF LOSS

I, Grace C. Vasquez, of legal age, Filipino and a resident of 05 Briz St.

Masbate City after having been duly sworn to in accordance with law, hereby
depose and say:

1. That I am the owner of a Drivers License with License No. EO3-

15501727;

2. That recently, I noticed that my Drivers License was missing, efforts

to locate in vain, and for all intents and purposes considered lost;

3. That I wish to manifest that said Drivers License was not given or
endorsed to anybody but simply lost;

4. That I have executed this affidavit to attest to the truth of all the
foregoing and satisfy the inquiry or requirements of any person or
office particularly the Philippine National Police and for other legal
purpose.

IN WITNESS WHEREOF, I have hereunto set my hands this ________. day

of __________, 2016 in City of Masbate, Philippines.

________________________
Affiant

JURAT

SUBSCRIBED AND SWORN to before me this ________________at Masbate

City, affiant exhibited to me her Postal ID No. PRN G16150284264 B
which expires on JULY 14, 2018.

Doc. No. _____;

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