REPUBLIC OF THE PHILIPPINES )

MARIKINA CITY ) S.S.

AFFIDAVIT OF LOSS

I, JAY LLYOD V. SEJALBO, of legal age, single, Filipino, and residing at Block
25 Lot 16 Tanguile Street corner Apitong Street, Marikina Heights, Marikina
City, after having been duly sworn in accordance with law, do hereby depose
and state that:

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

Office on ___________________ with Driver’s License No.________________
and a (Bank) Automated Teller Machine (ATM) card with savings account
number:___________________;
2. On _____ of July 2023 I decided not to use my motorcycle and commute
via public jeepney going to work because it was raining hard, and the
fact that the jeepney was full of passengers it was difficult for me to
reach my money in my pocket, hence, after I paid my fare, my card
holder containing my abovementioned Driver’s License and ATM card
must have slipped from my pocket because upon arriving at our office, I
noticed that my card holder was missing;
3. After diligent search in our house, my bag and in our office, the said card
holder containing my Driver’s License and ATM card was nowhere to be
found anymore;
4. I am executing this affidavit to attest to the truth of the foregoing
circumstances and for all legal intents and purposes.

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

_________________, 2023 at _____________________, Philippines.

JAY LLYOD V. SEJALBO

Affiant

SUBSCRIBED AND SWORN to before me this ____ day of _______________ 2023

at Marikina City, Philippines. Affiant personally known to me and was
identified by me through competent evidence of identity as defined in the 2004
Rules on Notarial Practice (A.M. No. 02-8-13-SC). Affiant/s exhibited to me his
___________________________, with his photograph and signature appearing
thereon, with no. ________________.

Witness my hand and seal this ___ day of _____________________ 2023

NOTARY PUBLIC

Doc. No. _____

Page No. _____
Book No. _____
Series of 2023