Republic of the Philippines…)

City of Mandaluyong………) S.S.

AFFIDAVIT OF LOSS

KNOW ALL MEN BY THESE PRESENTS:

I, Jinny Marcelo of legal age, Filipino, single/married, and a resident of 1234 barangay Pembo Marikina City, after
having been sworn in accordance with law, hereby deposes and states the following:

1. I am holder/owner/ or possessor of the following identification card / document: Driver’s License issued by Land
Transportation Office with ID Number 123456 on Nov 23, 2019.

2. I have lost the said drivers License on December 25, 2020 despite diligent effort to locate the the said ID, I can no
longer be found it.

3. I execute this affidavit to attest to the truth of the foregoing.

Signed on the date and at the place indicated below.

(SIGNED)
JINNY MARCELO
Affiant
(Signature over Printed Name)
Competent Evidence of Identity
ID: 123456
issued on: January 21, 2020
at: Mandaluyong City

SUBSCRIBED and SWORN TO before me on the date and at the place indicated below. The affiant
exhibited to me his competent evidence of identity as indicated above.

Signed this January 28, 2021at Mandaluyong City, NCR, Philippines.

WITNESS MY HAND AND SEAL.

(SIGNED)
ATTY KRIZALDY REGLO
Notary Public
Doc. No. 23
Page No.67
Book No. I I
Series of 2021