Republic of the Philippines)

Province of Rizal ) S.S.

City/Municipality of Antipolo )
x-----------------------x

AFFIDAVIT OF LOSS

I, AMELIA CABATAC BRILLANTES, of legal age, Filipino, married and a

resident of L6 B5 PH4 Ephesian Street, Jordan Plains Subdivision,
Novaliches Quezon City, after having been duly sworn to in accordance
with law, 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
corresponding Non-Professional Driver's License;

2. That on October 22, 2019 , my wallet including the above-mentioned

driver’s license was accidentally misplaced and got lost;

3. Efforts were exerted to locate the said Non-Professional Driver's License

Card, but despite diligent search, it could not be found and the same is
now beyond recovery;

4. 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 Card , in lieu of the one that was lost;

IN WITNESS WHEREOF, I have hereunto set my hand this day

of___________at Antipolo City, Philippines.

AMELIA CABATAC BRILLANTES

Affiant

SUBSCRIBED AND SWORN to me before this day of

___________________in the City of Antipolo City, Philippines, affiant having
exhibited to me her SSS ID No. 33-3037501-7 she acknowledged that she
executed the same and avowed under penalty of law the truthfulness of the
foregoing statements.

Doc. No.
Page No.
Book No.
Series of 2019