Republic of the Philippines )

Province of La Union )S.S.

Municipality of Naguilian )
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AFFIDAVIT OF LOSS
I, JHAKE A. MINA, Filipino, of legal age, married and a resident of Brgy. Nagsidorisan,
Naguilian, La Union, Philippines, after being duly sworn to in accordance with law, hereby depose and
state:

1. That I am a duly-licensed driver in accordance with pertinent Land Transportation laws, rules
and regulations and was issued a corresponding Driver's License;

2. That on June 6, 2019, while I was on board a tricycle from Ambaracao Norte going to
Natividad, Naguilian, La Union, I lost my Driver’s License and Municipal ID which I usually
place in front of the tricycle;

3. That despite diligent search and efforts to locate my Driver's License and Municipal ID, I
could not find the same such that I now believe that they are now lost beyond recovery;

4. That said Driver's License has not been confiscated by the LTO, Police or other Traffic
Enforcers for any traffic violation;

5. As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing and to
support my application for the issuance of the above-mentioned Driver’s License and
Municipal ID in lieu of the one that was lost.

IN WITNESS WHEREOF, I have hereunto set my hand this 6th day of June 2019 at Naguilian,
La Union, Philippines.

JHAKE A. MINA
Affiant

SUBSCRIBED AND SWORN to before me this 6th day of June 2019 at Naguilian, La Union,
Philippines.