Republic of the Philippines )

In the City of Baguio ) S.S.

AFFIDAVIT OF LOSS

I, JEFFREY L. JACOB, of legal age, married, Filipino citizen, and with

residence address at 1st Road Quezon Hill, Baguio City, under oath, depose and
state that:

1. I am a duly-licensed driver in accordance with pertinent Land

Transportation laws, rules and regulations, and was issued a Driver’s
License by the Land Transportation Office;

2. The Driver’s License issued to me by the Land Transportation Office was

misplaced and or lost by me sometime in 2009 when I was in Saudi
Arabia;

3. Despite diligent search and efforts to locate my Driver’s License, I could

not find the same that I know believe that it is now beyond recovery;

4. My Driver’s License is now beyond recovery and is considered lost;

5. The said Driver’s License has not been confiscated by the LTO, Police or
other Traffic Enforcers for any traffic violation;

6. I am executing this Affidavit of Loss to attest to the truth and veracity of

all 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 20th day of

September 2012, Baguio City, Philippines.

JEFFREY L. JACOB
Affiant

SUBSCRIBED AND SWORN TO personally before me this 20th day of

September 2012 at Baguio City. Affiant whom I identified through his CTC with
No. 33047923, issued on September 20, 2012, at Baguio City, signed the document
in my presence and avowed under penalty of law to the whole truth of the
contents of the foregoing document.

Doc. No. 72 ;
Page No. 16 ;
Book No.VIII ;
Series of 2012.