REPUBLIC OF THE PHILIPPINES)

CALOOCAN CITY ) S.S.

AFFIDAVIT OF LOSS

I, , Filipino, of legal age, married, and with residence address at, after
being duly sworn to in accordance with law, hereby depose and state:

1. That I was issued a Driver’s License by the Land Transportation

Office (LTO) and a Unified Multi-purpose ID under my name;

2. That on August 13, 2022, my wife’s wallet, where my Driver’s

License and UMID were placed, fell from her jacket’s pocket and got lost while
she was riding the motorcycle along Galas St., Brgy. Bignay, Valenzuela City;

3. That despite diligent search and efforts to locate my IDs, I could not
find the same such that I now have reasons to believe that they are now lost and
cannot be recovered;

4. My IDs have not been confiscated by any government agency;

5. As such, I am executing this Affidavit of Loss to attest to the truth of

the foregoing and for whatever legal purpose this may serve.

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

___________, 2022, in Caloocan City.

Affiant

SUBSCRIBED AND SWORN TO BEFORE ME, a Notary Public for and

in Caloocan City, this __ day of _________, 2022, affiant personally came and
appeared with as his competent proof of identity, bearing his photograph and
signature.

Doc. No. __;

Page No. __;
Book No. __;
Series of 2022.