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Republic of the Philippines)

Cagayan de Oro City...) s.s

AFFIDAVIT OF LOSS
I, JOSE LORENZO D. BELEN, of legal age, Filipino, and a resident
of Sta. Cecilia, Gusa, Cagayan de Oro City, after having been sworn to
in accordance with law do hereby depose and say:
1. That in the evening of September 29, 2015, I was on my way to
meet a friend for dinner somewhere in Makati;
2. That while I was walking, I noticed that my wallet was no longer
inside my back pocket. I also checked my bag but it was not
there;
3. That inside my wallet are my identification cards, money and my
drivers license;
4. That I exerted all efforts to look for it but my effort was rendered
futile and now I consider it lost beyond recovery;
5. That I am executing this affidavit for the purpose of getting
another drivers license, to attest to the truthfulness of the
foregoing and for whatever legal purposes this may serve;
JOSE LORENZO D. BELEN
Affiant
SUBSCRIBED AND SWORN TO, before me this 15 TH day of October
2015, in the City of Cagayan de Oro personally appeared to me Jose
Lorenzo D. Belen showing his passport issued here in Cagayan de
Oro City.
I HEREBY CERTIFY that I have personally examined the affiant
and I am satisfied that he has read and understood his affidavit, the
content of which he has personal knowledge.