REPUBLIC OF THE PHILIPPINES

Province/City: Quezon City

AFFIDAVIT OF LOSS

I, RODELIO D. MACALOYOS of legal age and residing/with address at

Bagumbong Dulo, Caloocan CIty, under oath, state:

1. THAT on 24 October 2017 at San Juan while driving home with my

motorcycle, my driver’s license fell without my knowledge;

2. THAT the details of my driver’s license LICENSE NUMBER:H0899001889;

3. THAT I exerted diligence efforts to locate my license and to identity the

finder but to noavail and therefore I considered the same as lost and cannot be
found;

4. THAT I am executing this Affidavit to attest to the truth of the foregoing

facts and to use the same for whatever legal purposes it may serve

IN WITNESS WHEROF, I hereunto affix my signature this ___________________at

Quezon City.

RODELIO D. MACALOYOS

AFFIANT

SUBSCRIBED AND SWORN to before me this _______________ at

__________________, Affiant exhibiting to me his Community Tax Certificate
bearing No. ________________ issued at _________________ on
___________________________.

Doc No. ________;

Page No. _______ ;

Book No. _______;

Series of 2017.