REPUBLIC OF THE PHILIPPINES )

QUEZON CITY ) SS.

AFFIDAVIT OF LOSS

I, HERMILINDA D. FLOR , Filipino, of legal age, and a resident of Lot17,Blk17

Sun Flower Maligaya Caloocan City , after having been duly sworn in
accordance with law, hereby depose and say:

1. That I am a owner/ possessor of the PVAO ID;

2. That on December 6, 2017 I was looking for the above mentioned item but
to my surprice the same could not be found;

3. That despite diligent efforts to locate the same all efforts proved fruitless up
to the present and fear that the same was lost beyond recovery.

4. That I am executing this affidavit to attest to the truth of the foregoing

instrument and for any legal purposes and intent this may serve.

IN WITNESS WHEREOF, I have hereunto affixed my signature this 15th day

of February 2018 at Quezon City, Philippines.

HERMILINDA D. FLOR
Affiant
ID No. ___________
Issued on ________
Issued at _________

IN WITNESS WHEREOF, I have hereunto set my hand this 15 th day of

February, 2018, in Quezon City. Affiant exhibited to me his/her government
issued ID as indicated above as proof of his/her identity.

Doc No.______
Page No._____ NOTARY PUBLIC
Book No._____
Series of 2018.