Republic of the Philippines)

Province of ____________________) S.S.

City/Municipality of _____________)
x---------x

AFFIDAVIT OF LOSS

I, JESSIE BOBILA RAFANAN, Filipino, of legal age, married, and with

residence at RD 2 TRINIVILLE T., LA TRINIDAD, BENGUET, Philippines, after
being duly sworn to in accordance with law, hereby depose and state:

1. 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 with number A01-73-001036
which is valid until 2018-04-13;

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

3. 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;

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

5. 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.

JESSIE BOBILA RAFANAN

AFFIANT

Doc. No. ____________

Page No. ____________
Book No. ___________
Series of 2017