REPUBLIC THE PHILIPPINES)

BATANGAS CITY ) S.S.

AFFIDAVIT OF LOSS

I, ADRIANO C. BAGSIT III, married of legal age, Filipino,

and a resident of Batangas City, after having been duly sworn to
in accordance with law, hereby, depose, and state that:

[1] I am a holder of a Driver’s License, issued by the

Land Transportation Office (LTO);

[2] Recently, while I was searching for the said Driver’s

License, I have discovered that the same was lost;

[3] I exerted diligent efforts to find and locate the said

item but the same proved futile;

[4] Moreover, the said item was not confiscated nor made
subject of apprehension by any government authority;

[5] Furthermore, said item has not been returned to me;

[6] I am executing this affidavit to attest to the truth and

to inform the proper authorities of all the foregoing facts, and
for whatever legal purpose this Affidavit may serve.

IN WITNESS WHEREOF, I have hereunto set my hand

this 05 November 2018, at Batangas City.

ADRIANO C. BAGSIT III

Affiant
ID No.____________________________

SUBSCRIBED AND SWORN TO BEFORE ME this 05

November 2018, at Batangas City, affiant/s exhibited to me
his/her/their Identification Card with number stated above.

SONNY JOSE M. RICABLANCA

Notary Public
Until 31 December 2018
PTR No. 3022119 01-03-18 Batangas
City
IBP Lifetime No. 019079
Doc. No. 411 Roll No. 69544 Serial No. 2017-20
Page No. 84 MCLE Exempted,SONNYpursuant to MCLE
JOSE M. RICABLANCA
Book No. XIII Notary Public
Governing Board Order No. 1, S.2008
Series of 2018. Until 31 December 2019
Zenaida Arcade,
PTR43No.M.H. del
3022119 PilarBatangas
01-03-18 St., City
Batangas City IBP No. 1065629 Batangas City
Roll No. 69544 Serial No. 2017-20
MCLE Exempted, pursuant
Pageto1MCLE
of 2 Governing Board
Order No. 1, S.2008
Affidavit of Loss
Zenaida Arcade, 43 M.H. del Pilar St., Batangas City
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Affidavit of Loss