REPUBLIC OF THE PHILIPPINES}

SAN PEDRO CITY, LAGUNA} S.S.

AFFIDAVIT OF LOSS

I, Aaron Dyllan Clark Pacheco, of legal age, Filipino, with residence and postal
address at B12 L6 Brgy United Bayanihan San Pedro City, Laguna, after having been
duly sworn to in accordance with law hereby depose and state that:

1. By virtue, and mandate of the Land Transportation Office – Las Pinas, I

was issued a driver’s license card on January 28, 2019;
2. Said driver’s license card was lost sometime on May 15, 2020
at Robinsons Galeria South Mall;
3. Hereunder are the facts and circumstances surrounding the loss of my
Drivers License the identification number is: N26-19-003542
Expiration date: June 12, 2023
4. I made diligent search to recover my driver’s license card but proved
futile;
5. For all legal intents and purposes the said driver’s license card is now
considered lost and beyond recovery;
6. I am executing this affidavit to attest to the truth of the foregoing and for
whatever legal purpose/s it may serve.

FURTHER AFFIANT SAYETH NAUGHT.

IN TRUTH THEREOF, I have hereunto set my hand this _____________ day of

___________________20__, at __________________________, Philippines.

Aaron Dyllan Clark Pacheco

Affiant

SUBSCRIBED AND SWORN to before me this ___________________ day of

______________________ 20__, affiant exhibited to me his/her Residence Cert. No.
__________________ issued at ___________________ on ______________________.

NOTARY PUBLIC

Doc. No. ___________;

Page No. ___________;
Book No. ___________;
Series of 20___