Republic of the Philippines )

Province of Palawan ) S.S

City of Puerto Princesa )

AFFIDAVIT OF LOSS

I, MICHAEL ANTONIO S. PACURIBOT , of legal age, Filipino, and a

resident of Gabinetero, Bancao-Bancao, Puerto Princesa City, Palawan, after having
been duly sworn in accordance with law, do hereby deposes and say;

1. That I am the absolute owner of Non-Professional Driver’s License Card

No._____________________, issued by the Land Transportation Office;

2. That the above said Driver’s License Card issued to me was misplaced
somewhere or fell unnoticed;

3. That despite our diligent effort to locate and recover, all effort proved to be
futile and hence, for all legal intents and purposes the said Driver’s License
is deemed lost;

4. That, I declare under oath the said Driver’s License Card was not
confiscated by PNP, Highway Patrol Group nor any agency in charge with
the enforcement of traffic rules;

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

facts and to comply with the requirements of the law and the Land
Transportation Office for replacement and re-issuance of my Driver’s
License Card and for whatever legal purpose the same may serve.

IN WITNESS WHEREOF, I have set my hand this 21th day of January, 2020, at
the City of Puerto Princesa, Palawan.

MICHAEL ANTONIO S. PACURIBOT

Affiant

SUBCRIBED AND SWORN before me this day of 21th day of January, 2020, at
the City of Puerto Princesa, Palawan.

Doc No. _______

Page No. ______
Book No. _____
Series of 2020