REPUBLIC OF THE PHILIPPINES)

CITY OF MAKATI ) S.S.

AFFIDAVIT OF LOSS

I, JUAN DELA CRUZ, of legal age, single, Filipino, and a resident of Unit 001
Cityland Makati Executive Tower 11, Dela Rosa St., Makati, Philippines, after having been
sworn to in accordance with law hereby depose and state that:

1. I am a licensed driver holding a Driver's License issued by the Land

Transportation Authority (LTO) - Driver's License Renewal Center in Ayala MRT
Station, EDSA, Makati City.

2. In the afternoon of 01 September 2020, I was inside LRT Taft Avenue Station to
top-up my Beep card as I am going to Roosevelt Avenue. When I was about to
pay, I discovered that my wallet containing my Driver's License was missing. I
was not sure if it fell from the pocket of my jeans or was stolen/snatch while I
was walking on the busy corner of Taft Ave.

3. I took diligent search and efforts to locate my wallet but I could not find the
same, hence, I believe it is now beyond recovery.

4. My Driver's License has not been confiscated by the LTO, Police or other

Traffic Enforcers for any traffic violation.

5. I am executing this Affidavit of Loss to attest to the truth of the foregoing

statement, and to request for a replacement of my Driver's License, and for
whatever legal purpose it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this ______ day of

September 2020 at _____________, Philippines.

JUAN DELA CRUZ

Affiant

SUBSCRIBED AND SWORN to before me this _______ day of September, 2020 in

the City of _________________. Affiant exhibited to his competent evidence of identity as
_____________________.

Notary Public

Doc. No____;
Page No. ___;
Book No. ___;
Series of 2020.