REPUBLIC OF THE PHILIPPINES)

Makati City )
x-----------------------x

AFFIDAVIT OF LOSS

I, JOSE BONIFACIO, Filipino, of legal age, with address at San

Andres, Manila, after having been duly sworn in accordance with law,
depose and state: That –

1. I am the holder of a Non-Professional Driver’s License (NPDL)

No. N03-67-082177 issued by the Department of
Transportation, Land Transportation Office;

2. I lost the said NPDL ID on or about 21 October 2020, at the

Landmark Shopping Mall in Makati City at around
6:30 p.m., during the rush hour then prevailing;

3. Despite diligent efforts to locate the said NPDL No. N03-67-

082177, all efforts proved futile;

4. I execute this Affidavit of Loss to attest and to affirm the

truth of the foregoing statements and for the purpose
of securing a replacement from the SSS.

FURTHER AFFIDANT SAYETH NONE.

Jose Bonifacio
Affiant

SUBSRIBED AND SWORN to before me this ___ day of ________

20____, affiant exhibiting to me a colored photocopy of her NPDL No.
N03-67-082177 issued by the Department of Transportation, Land
Transportation Office with his picture attached thereon as a competent
proof of his identity.

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 2020.