REPUBLIC OF THE PHILIPPINES)

C I T Y O F M A K A T I ) S.S.

AFFIDAVIT OF LOSS LICENSE

I, ALBERT R. CAPON, of legal age, Filipino citizen, with residence address at 207
Sunrise Street, Barangay La Paz, Makati City, after having duly sworn to in accordance
with the law do hereby depose and say:

That I am the holder and in possession of PROFESSIONAL DRIVER’S LICENSE,

with number N03-13-017413, which was duly issued by the Land Transportation Office
(LTO);

That due to inadvertence, the said PROFESSIONAL DRIVER’S LICENSE was

LOST and despite earnest effort to locate it, the same could no longer be found;

That aforesaid PROFESSIONAL DRIVER’S LICENSE was not confiscated,

revoked or cancelled for any violation of law but for the only reason stated herein;

That I would like to request the Land Transportation Office (LTO) for the
replacement of the above mentioned lost license;

That this affidavit is being executed to attest to the fact of the lost PROFESSIONAL
DRIVER’S LICENSE and to secure a duplicate copy thereat in lieu of the lost and to
report this matter to the authorities concerned.

AFFIANT SAYETH NAUGHT.

IN WITNESS WHEREOF, I hereunto set my hand on this 05th day of February 2022,
at Makati City, Philippines.

ALBERT R. CAPON
Affiant

SUBSCRIBED AND SWORN to before me on this 05th day of February 2022, at Makati
City, Philippines.

DOC. NO.
PAGE NO.
BOOK NO.
SERIES OF 2022