Republic of the Philippines)

City of Tacloban ) s.s.

Province of Leyte )
x-------------------------------x

AFFIDAVIT OF LOSS

I, RAFAEL L. LIBAO, of legal age, married, Filipino citizen and a

resident of Brgy. San Vicente, Catbalogan, Samar, after having been duly
sworn to in accordance with law do hereby depose and say;

1. That I am a holder of several identification cards, as herein-

below enumerated, to wit:

a) UMID ID
b) ATM CARD – LAND BANK
c) TIN CARD
d) PRC (Criminologist) ID
e) DRIVER’S LICENSE

2. That above-mentioned cards were kept in my possession and

were placed inside my wallet;

3. That sometime on June 24, 2018, while on duty as Patroller, I

discovered that the said items which were placed together in my wallet
fell out of my pocket contained therein were my important documents
and ID’s as above-mentioned;

4. That diligent efforts to retrieve the same was exerted but proved
futile, hence, for all intent and legal purposes I considered them lost and
beyond recovery;

5. That relative to lost driver’s license was not confiscated by any

law enforcement authorities for violation of any traffic laws and
regulations;

6. That I am executing this affidavit to attest the truth and veracity

of all the foregoing statements.

IN WITNESS WHEREOF, I have hereunto affix my signature this

16 day of April 2019 at Tacloban City.
th

RAFAEL L. LIBAO
Affiant

SUBSCRIBED AND SWORN to before me this 16th day of April

2019 at Tacloban City. Affiant exhibited to me his PNP ID with no.
18G160296 valid until 01-09-2021.

Doc. No. ____

Page No. ____
Book No. ____
Series of 2019