REPUBLIC OF THE PHILIPPINES )

CITY OF CAGAYAN DE ORO ) SS.

AFFIDAVIT of LOSS

KNOW ALL MEN BY THESE PRESENTS:

I, REYNALDO ARAT y DUHAYLUNGSOD, Filipino, married, of legal age and

a resident of Hayes Street, Barangay 40, Cagayan de Oro City, after having been duly
sworn to in accordance with law, depose and say:

That I am employed with the Housing and Land Use Regulatory Board as a
driver since 2014;

That I am a holder of a valid Professional Drivers License No. K0204103451

which is to expire on 13 October 2018;

That on 26 July 2017 at around one thirty in the afternoon, while I was driving at
Rizal Abejuela Street, a passenger jeepney hit my rear bumper;

That the Road Traffic Administrator (RTA) approached us and got the OR/CR of
our agency vehicle and my drivers license;

That approximately after thirty minutes, the same RTA approached me to get my
license again;

That I told him that I already gave it to him the first time he approached me;

That under the circumstances, all efforts to retrieve the same proved futile and
fruitless, that I now consider the license card irretrievable lost;
That I went to the Police Station to file a blotter report on the incident (attached
herewith as Annex A);
That I am making this Affidavit to attest to the above facts, in order to have my
professional drivers license card replaced and for whatever legal purpose this may
serve.

IN WITNESS WHEREOF, I hereby affix my signature this 26 th day of July 2017 at

Cagayan de Oro City, Philippines.

______________________________
REYNALDO D. ARAT
Affiant

Signed in the presence of:

___________________________ __________________________

SUBSCRIBED AND SWORN to before me this 27th day of July 2017 at Quezon City,
Philippines, Affiant exhibiting his Competent Evidence of Identity UMID CRN # 0008-
1304944-9.

WITNESS MY HAND AND SEAL on the date and place mentioned above.

Doc. No.
Page No.
Book No.
Series of 2017