AFFIDAVIT OF LOSS

I, MARIA RIZZA H. MANGUBAT, of legal age, single, with address at, Brgy.
Talisay, Lipa City, Province of Batangas, after having been sworn, hereby
depose and say:

1. That I am the holder of a Non-Professional Driver’s License with Number

N01-19-066623 which will expire on 30 September 2024 issued by the Land
Transportation Office Lipa City;

2. That I lost the above-mentioned Driver’s License last 09 September 2022 at

a grocery store in Lipa City;

3. That my driver’s license was neither stolen, confiscated, forfeited, nor

alarmed as lost to any government agency;

4. That after diligent and exhaustive efforts of locating the same, I could no
longer locate my Driver’s License;

5. That I am executing this Affidavit to attest to the foregoing and for whatever
legal purpose it may serve.

21 September 2022, Lipa City.

MARIA RIZZA H. MANGUBAT

Affiant

Republic of the Philippines)

Lipa City, Batangas ) S.S.

Subscribed and sworn to before me on this 21th day of September 2022,

affiant exhibiting her PhilHealth ID 09-250995171-5 as her competent proof of
identity.

Witness my hand and notarial seal...

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