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Republic of the Philippines}

City of MANILA } S.s.

AFFIDAVIT OF LOSS

I, ROZELLE SHAYNE R. RAMOS, of legal age, single, Filipino,


with residing at 431 Burgos Street Fortune Village 7, Barangay
Parada, Valenzuela City, after having been duly sworn to in
accordance with law, hereby depose and state that:
1. I am a bona fide holder of an LTO Non-Professional Driver’s
License;

2. The afore-mentioned Driver’s License was lost or


misplaced while in my possession;

3. I exerted efforts to locate the said Driver’s License but to


no avail and are now considered lost and beyond recovery; and

4. This Affidavit of Loss is being executed to attest to the


truthfulness of the foregoing facts and circumstances.

This _____ day of June 2019, City of Manila.

ROZELLE SHAYNE R. RAMOS


Affiant

SUBSCRIBED AND SWORN TO before me, this


______________________ in the City of _________, by the affiant who
presented to me her Passport with number _________________ issued
on ________________________ at ________________________.

NOTARY PUBLLIC

Doc No. ______;


Page No.______;
Book No. _____;
Series of 2019.

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