REPUBLIC OF THE PHILIPPINES)

CITY OF ORMOC ) S.S.

x---------------------------------------------x

AFFIDAVIT OF LOSS
I, MARICEL ALQUIZAR MENDOZA, of legal age, Filipino, single, and a resident of Barangay
District 16, Ormoc City, Leyte, after having been duly sworn to in accordance with law,
depose and state THAT:

1. I am a duly-licensed driver in accordance with pertinent Land Transportation laws,

rules and regulations, and was issued a corresponding Driver's License with number
H0305001194 and that I usually keep said license in my wallet;

2. Sometime in 2016, when I was on my way home, I realize that said wallet containing
my Driver’s License was no longer in my pocket;

3. Efforts were exerted to locate said wallet and driver's license, but in spite of diligent
search, it could not be found and the same is now beyond recovery;

4. Said Driver's License has not been confiscated by the LTO, Police or other Traffic
Enforcers for any traffic violation;

5. As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
and to support my application for the issuance of a new Driver's License, in lieu of
the one that was lost and for whatever legal purpose this may best serve.

IN WITNESS WHEREOF, I have hereunto set my hand this ___________________ in Ormoc City,
Leyte, Philippines.

MARICEL ALQUIZAR MENDOZA

Affiant
ID No.: UMID 0111-7700172-4

SUBSCRIBED AND SWORN to me before this _________________________, affiant exhibited to me

her identity card stated above which serves as competent evidence of her identity.

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 2023.