REPUBLIC OF THE PHILIPPINES)

City of Cebu ) S.S.

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AFFIDAVIT OF LOSS

I, JULIETA D. PAZA, Filipino, of legal age, and residing at Block 5 Lot 15 Urbanville
Homeowners, Tapoko, Pit-os, Cebu City, Philippines, after being duly sworn to in
accordance with law, hereby depose and state:

1 That I am a duly licensed driver and was issued with a Driver’s License by Land
Transportation Office (LTO);
2 That sometime on February 19, 2021, Friday, I inadvertently lost the said
license while riding my motorcycle ;
3 That diligent efforts to search the said license proved futile such that I believe it
is now beyond recovery;
4 That said Driver’s License has not been confiscated by law enforcement agency
or has no pending or unresolved case for apprehension, alarm, suspension or
revocation;
5 As such, I am executing this affidavit to attest to the truth of the foregoing facts
and to support my application for the issuance of a new Driver’s License, in lieu
of one that was lost.

IN WITNESS WHEREOF, I have hereunto set my hand this 15th day of March 2021
at Cebu City, Philippines.

JULIETA D. PAZA
Affiant

SUBSCRIBED AND SWORN to before me this 15th day of March 2021, affiant
showing to me her ID________________________________________ as competent proof of his identity.

Doc. No.______;
Page No.______;
Book No.______;
Series of 2021.