REPUBLIC OF THE PHILIPPINES )

CITY OF ANGELES ) S.S.

AFFIDAVIT OF LOSS

I, JAYLENE MULI LUMANLAN, of legal age, Filipino, and a resident of San Pablo St.,
Mt. View, Balibago, Angeles City, after being sworn in accordance with law, depose and state
that:

1. A driver's license was issued to me by the Land Transportation Office;

2. Sometime in July of 2020, the aforesaid Driver's License was kept in my

wallet. Unfortunately, my wallet went missing when I left the same in our
house when I went out to buy something;

3. Diligent efforts were exerted to retrieve the aforesaid wallet where the said
driver's license was kept but to no avail;

4. I am executing this affidavit in order to attest to the truth of the foregoing

circumstances.

IN WITNESS WHEREOF, I have hereunto set my hand on this 8 th day of January 2021
in Angeles City.

JAYLENE MULI LUMANLAN

Affiant

SUBSCRIBED AND SWORN to before me in the City of Angeles this 8 th day of January 2021 by
Jaylene M. Lumanlan who have satisfactorily proven to me her identity through her PhilHealth
ID with No. 07-025382044-4, that she is the same person who personally signed before me the
foregoing and acknowledged that she executed the same voluntarily.

Doc. No. ____;

Page No. ____;
Book No. III;
Series of 2021.