Republic of the Philippines )

Quezon City ) s. s.

AFFIDAVIT OF LOSS
I, ALFREDO D. FRIAS, of legal age, Filipino and a resident of Sitio Singalong,
Barangay San Jose, City of Antipolo, Province of Rizal after having been duly sworn on
oath in accordance with law, hereby depose and state, THAT-

1. I am possessor of Driver’s License issued by the Land Transportation

Office bearing license No. D 19-17-007579 with restriction, A, A.1, B, B.1, B.2;

2. Said driver’s license was lost when I fell my wallet while riding at Public
Utility Tricycle;

3. I notice only the lost of my wallet where my driver’s license was kept, upon
reaching my house;

4. The undersigned took diligent efforts to look for the said wallet and driver’s
license proved futile;

5. I am executing this statement to attest to all the above facts and to request
the proper personnel of Land Transportation Office for the issuance of duplicate copy of
driver’s license.

IN WITNESS WHEREOF, I have signed my name below this ___ day of March,
2023 at Quezon City, Philippines.

ALFREDO D. FRIAS
Affiant

SUBSCRIBED AND SWORN to before me this ___ day of March, 2023 at

Quezon City, Philippines, affiant exhibited to me his government issued identification
card with picture and signature as competent proof of his identity.

Doc. No.:
Page No.:
Book No.:
Series of 2023