REPUBLIC OF THE PHILIPPINES

CITY OF CABANATUAN )S.S.

X--------------------X

AFFIDAVIT OF LOSS

I, FRANCISCO VILLAFLOR QUIBUYEN III, of legal age, Filipino and

a resident of Brgy. Aduas Centro, Cabanatuan City, Nueva Ecija, after having been
duly sworn to in accordance with law, hereby depose and say:

1. That sometimes in 2018, I was apprehended for a traffic violation for a

driving without helmet at Cabanatuan City Terminal and was issued a
Temporary Operator’s Permit (TOP);

2. That sometimes my wallet got lost without my knowledge which contains

IDs and the said TOP;

3. That despite diligent search to locate my wallet and said TOP the same
could no longer be found elsewhere;

4. That I am executing this affidavit to attest to the truth of the foregoing facts
and for whatever legal intents it may serve.

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

of _______2019, here at Cabanatuan City.

FRANCISCO V. QUIBUYEN III

Affiant

SUBSCRIBE AND SWORN to before me this ___th day of

____________ 2019, here at Cabanatuan City.

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