Republic of the Philippines)

Province of Pangasinan) S.S.

Municipality of Calasiao)

x---------x
AFFIDAVIT OF LOSS

I, Glenn P. Suico, Filipino, of legal age, single, and with residence at #79 Sitio Alegria
Dinalaoan, Pangasinan, Philippines, after being duly sworn to in accordance with law,
hereby depose and state:

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.

That sometime last week, said Driver's License was misplaced and got lost.

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;

That said Driver's License has not been confiscated by the LTO, Police or other
Traffic Enforcers for any traffic violation.

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 set my hand this _____________ at

_____________, Philippines.
Glenn P. Suico

AFFIANT

SUBSCRIBED AND SWORN to before me, this _____________, by _____________

who exhibited to me (his/her) Community Tax Certificate No. _____________ issued at
_____________, Philippines on _____________.

Notary Public

Doc. No. ______;

Page No. ______;

Book No. ______;

Series of ______;