Republic of the Philippines)

Province of Negros Oriental) S.S.

Municipality of Sibulan . . .)

AFFIDAVIT OF LOSS

I, MARC ANTHONY B. PAALAN, of legal age, married, Filipino and a

resident of Cangmating, Sibulan, Negros Oriental, after having been duly sworn to in
accordance with law, state and declare that:

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

Office (LTO), and I usually place it in my wallet;

2. That sometime on July 16, 2022, I was riding a bus from Dumaguete City,
Negros Oriental to Maslog, Sibulan, Negros Oriental and noticed that my wallet
containing the Driver’s License was not anymore in my belt bag. Perhaps, the said wallet
fell from my belt bag;

3. I have exerted diligent search and efforts to locate my wallet containing

the Driver’s License but the same has not been found or recovered up to the present such
that I now believe that it is now lost beyond recovery;

4. The said Driver’s License was not confiscated by any law enforcement
agency due to violations of traffic rules and regulations;

5. I am executing this Affidavit of Loss to establish the fact of loss of my

wallet containing the Driver’s License and to attest to the truthfulness and veracity of the
foregoing facts.

IN WITNESS WHEREOF, I have hereunto affixed my signature this

_____________ in Sibulan, Negros Oriental, Philippines.

MARC ANTHONY B. PAALAN

Affiant

SUBSCRIBED AND SWORN to before me, a Notary Public, on this

_____________, for the Municipality of Sibulan and the Province of Negros Oriental,
Philippines, the above-named affiant, exhibited to me his Police Clearance Certificate
No. 18857851 issued on August 01, 2022, WHO SIGNED IN MY PRESENCE the
foregoing document (Affidavit of Loss), and who avows under PENALTY OF LAW to
the whole truth of the contents of the same.

Doc No. ___;

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

Affidavit of Loss