Republic of the Philippines ) C I T Y O F D I P O L O G )s.s.

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AFFIDAVIT OF LOSS
I, _________________, Filipino, of legal age, single, and a resident of Romeros Apt., DMC Highway, Sta. Filomena, Dipolog City, under oath, hereby deposeth and sayeth: That I am a valid holder and possessor of a Drivers License card issued by the Land Transportation Office (LTO), Dipolog City; That just recently, I noticed that my wallet was lost in which the said card was usually kept; That despite earnest efforts to find my wallet and the said card, the same can no longer be found nor located; That the said card was not confiscated, surrendered, nor used as a collateral for any lien or encumbrance. Neither was it entrusted into the custody of any person. That I am, therefore, executing this affidavit in good faith to attest to the fact of the loss of my Drivers License. IN WITNESS WHEREOF, I have affixed my signature this 21st day of March, 2007, at Dipolog City, Philippines.

____________________ Affiant SUBSCRIBED AND SWORN to before me this ___th day of January, 2012, at ______City, Philippines, affiant exhibiting to me her community tax certificate number _____________ issued at ___________________, on ________________.

Doc. No. _ ___ : Page No. __ ___: Book No. _LXVII: Series of 2007

Notary Public Until December 31, 2007 PTR NO. 0323257 01-12-2007 IBP NO. 6542527 07-18-2006 Dipolog City