Republic of the Philippines)

Province of Masbate ) S.S.

City of Masbate )

AFFIDAVIT OF LOSS

I, Marvin Nazarene M. Pascual, of legal age, Filipino and a resident of

Brgy. Poblacion, Mandaon, Masbate, after having been duly sworn to in
accordance with law, hereby depose and say:

1. That I was issued a Professional Driver’s License issued by Land

Transportation Office;

2. That recently, I noticed that my Driver’s License and was missing,

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

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

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 Land Transportation Office and for other legal
purpose.

IN WITNESS WHEREOF, I have hereunto set my hands this _______________

in the City of Masbate, Philippines.

__________________________
Affiant

JURAT

SUBSCRIBED AND SWORN to before me this ______________________day of

at Masbate City,

Doc. No. 284;

Page No. 57;
Book No. III;
Series of 2018;