Republic of the Philippines)

City of Legazpi ) s.s.

x-------------------------------------------x

AFFIDAVIT OF LOSS

I, GABRIELA CORTEZ, of legal age, Filipino citizen, single and with address at P-4 Brgy.
San Andres, Sto. Domingo Albay, after having been duly sworn in accordance with law do
hereby depose and state:

1. I am the owner of a Driver’s License with License No. E0718009446 issued by LTO.

2. That on February 15, 2021, the said driver’s license was with me when I went to
Brgy. San Roque Sto. Domingo Albay for work. However, six days after, I noticed
that the said driver’s license was missing from my person.

3. Despite diligent search and effort to locate the said driver’s license, it can no
longer be found and considered lost for all intent and purposes;

4. I am executing this affidavit to attest the truthfulness of the foregoing

statements and for whatever legal purpose this may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this 26th day of March, 2021 at
Legazpi City, Philippines.

GABRIELA CORTEZ
Affiant
PRC License No. 0056789

SUBSCRIBED AND SWORN to before me this 26th day of March, 2021 at Legazpi City,
Philippines. Affiant exhibited to me her Identification Card indicated below her name as
competent proof of identity pursuant to 2004 Rules on Notarial Practice.

Doc. No. _____; NOTARY PUBLIC

Page No. _____;
Book No. _____;
Series of 2021.