Republic of the Philippines )

____________,___________ ) S.S

AFFIDAVIT OF LOSS

KNOW ALL MEN BY THESE PRESENTS:

I, GABRIEL ALBERTO N. GOMEZ of legal age, Filipino, single and a resident of 61

Flamingo Street, Greenmeadows Subdivsion, Barangay Ugong Nortem Quezon City, after
having been sworn in accordance with law, hereby depose and state the following:

1. I am the holder/owner or possessor of the following identification card / document:

a. Philippine Driver’s License with name, GOMEZ, GABRIEL ABLERTO
NORBERTE; License No. N03-15-009303; and, Address 61 Flamingo St.
Greenmeadows Ugong Norte Quezon City

b. Landbank Debit card under my name, GABRIEL ALBERTO N. GOMEZ

2. The above items were stored in a wallet which was lost at approximately 20000H on
March 9. In Araneta Coliseum Cubao, Quezon City.

3. I execute this affidavit to attest to the truth of the foregoing.

Signed on the date and at the place indicated below.

Affiant
Competent Evidence of Identity
ID: Passport No. EC7387588
Issued on April 2016
at: DFA NCR EAST

SUBSCRIBED and SWORN TO before me on the date and at the date and at the
place indicated below. The affiant exhibited to me his competent evidence of identity as
indicated above.

Signed this ______________ at ___________________,_________________

Philippines,
WITNESS MY HARD SEAL.

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