REPUBLIC OF THE PHILIPPINES )

DANAO CITY ) S.S.

AFFIDAVIT OF LOSS

I, TISHA ANGELIE CASIA GORRE Filipino, of legal age, single, and a

resident of CM Enriquez St., Brgy. Suba, Danao City, after having been duly
sworn in accordance with law, hereby depose and say:

1. That I am a holder of a Driver’s License Official Receipt valid as

temporary driver’s license issued by the Land Transportation Office
(LTO) of Danao City;

2. That I forgot the Driver’s License No. and Official Receipt No.
contained in the said Official Receipt serving as temporary driver’s
license;

3. That sometime in September 2018, I asked my auntie to go to the LTO

of Danao City to procure the Driver’s License card since during the
time I applied for one, there was no available card;

4. That unfortunately, my auntie lost the said Driver’s License Official

Receipt valid as temporary driver’s license;

4. That despite diligent search and efforts to locate the said Driver’s
License Official Receipt valid as temporary driver’s license, such has
not been found and it is my belief that it is now lost beyond recovery;

5. That said Driver’s License Official Receipt valid as temporary driver’s

license was not confiscated by the authorities for any reason. Neither
did I violate any rules and regulations;

6. That I am executing this affidavit to attest to the truth of the foregoing

facts and to request for a replacement and issuance of my Driver’s
License.

IN WITNESS WHEREOF, I have hereunto affixed my signature this 1st

day of June 2019 at Danao, Philippines.

TISHA ANGELIE CASIA GORRE

Affiant

SUBSCRIBED AND SWORN TO BEFORE ME, a notary public in and for

Danao City 1st day of June 2019 at Danao, Philippines. Affiant personally came
and appeared with her TIN ID # 345-966-750-000, bearing her photograph and
signature, known to me as the same person who personally signed the foregoing
instrument before me and avowed under penalty of law to the whole truth of the
contents of said instrument.

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