Republic of the Philippines

City of Kidapawan

Province of North Cotabato

Affidavit of Loss

I, Allen Mark B. Lupera, Filipino, of leagal age, single and with residence at Purok 6B, Bialong, Mlang,
Cotabato, Philippines, after being duly sworn to in accordance with law, hereby, depose and state:

1. I am a holder of a Driver’s License issued by the Land Transportation Office, Kidapawan City;
2. I lost said driver’s license on June 13, 2017 and that I exerted all efforts to locate the same but I
could not remember exactly where I paced it and it is considered lost for all legal purpose;
3. Said driver’s license was not confiscated by any officer of the law by reason of any violation of
any law, ordinance, presidential decree or rules and regulation of the said office; and neither
was it offered as collateral for any loan;

I am executing this affidavit to attest to the foregoing facts;

IN WITNESS WHEREOF, I have hereunto set my hand this 15th of June in the City of Kidapawan,
Philippines.

ALLEN MARK B. LUPERA

Affiant

SUBSCRIBED AND SWORN to before me this 15th of June in the City of Kidapawan, Philippines, affiant
having exhibited to me his community tax no. 12345 , issued on January 30, 2017 at Mlang,
Cotabato.

Doc no. 12345

Page no. 12345

Book no. 12345

Series of 2017