Republic of the Philippines )

_______________ ) S.S.
Province of Rizal )

AFFIDAVIT OF LOSS

I, JUAN DELA CRUZ, of legal age, single, Filipino citizen, with residence
address at Blk 7__ Lt __, Area C, Purok 1, San martin 1, Taytay, Rizal under oath,
depose and state:

(1) I am the owner/holder/possessor/bearer of a Driver’s License issued to

me by the Land Transportation Office. Unfortunately, I was not able to
keep a copy, nor I was able to memorize the license number;

(2) That the said Driver’s License along with my voter’s ID got lost;

(3) That despite diligent efforts has been exercised in order to find and
locate the said passport, the same could no longer be found and proved
to be beyond recovery.

(4) That this affidavit was executed to attest the truth of the foregoing and
for whatever legal purposes it may serve best.

IN WITNESS WHEREOF, I have here unto set my hand this 16 rd day of February
2021 at __________________-, Rizal, Philippines.

JUAN DELA CRUZ

Affiant

SUBSCRIBED AND SWORN to before me this 16rd day of February 2021 at

the __________________, Rizal, Philippines, affiant personally known to me
and exhibiting to me his competent evidence of identity.

PEDRO JAUN
Notary Public for the Province of Rizal
Brgy. Road, Taytay
Admin. Matter PNC-7__-MB-2018 until Dec. 31,
2020
Extended by Supreme Court B.M. No. 3795
Roll of Attorneys No. 111111
IBP Lifetime Member No. 123456BUL
PTR No. 9876544123– 04 January 2021-Taytay, Rizal
MCLE Comp. No. VI – 019231931 – 12 – 07-18
Doc. No: 111
Page No: 22
Book No: X
Series of 2021.