REPUBLIC OF THE PHILIPPINES)

CITY OF ) S.S.
x-----------------------------------------x

AFFIDAVIT OF LOSS

I, RAYANGELO A. PACTOLERIN, of legal age, Filipino, and a resident of Block 29, Lot 45,
Phase A, Istana Subdivision, Barangay Amaya II, Tanza, Province of Cavite, after having
been duly sworn to in accordance with Philippine law, hereby depose and truthfully
state THAT:

1. I am the owner of a driver’s license lawfully issued to me and that the same specifically
bears my own name;

2. Sometime on February 2023, I unknowingly dropped my wallet with my official driver’s

license inside while I was travelling from Tanza, Cavite to Makati City, Metro Manila;

3. Efforts were exerted to locate my wallet and my driver’s license, however, said efforts
proved unfruitful;

4. That despite subsequent further diligent efforts exerted by me and my family, I could no
longer find my wallet and my driver’s license, thus both items are now deemed
IRRETRIEVABLE and forever LOST;

5. As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing and
to support my request for the issuance of a new driver’s license, AND FOR ALL LAWFUL
INTENTS AND PURPOSES

IN WITNESS WHEREOF, I have hereunto set

my hand this ___________________ in ___________________, Philippines.

____________________
Affiant

SUBCRIBED AND SWORN TO before me this ___________________ in

_________________, Philippines, affiant exhibiting to me his/her competent
evidence of identity by way of __________________ bearing number
________.

Doc. No. _____;

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