REPUBLIC OF THE PHILIPPINE]

CITY OF SORSOGON ] SS.

AFFIDAVIT OF LOSS
I, CHRISTOPHER C. GAJULTOS, of legal age, single and presently
residing at #247 Rizal St., Barangay Sirangan, Sorsogon City, after being duly
sworn to in accordance with law, DEPOSE and STATE:

1. That sometime in August 2009 I was apprehended for violating

traffic regulations i.e. driving without helmet and without side
mirrors;

2. That as such, I was issued a Traffic Citation through a TOP ticket

which I placed inside my wallet;

3. That sometime in January 5, 2019, while I was travelling to

Manila, my wallet fell, which contained, among other things, the
said TOP Ticket. I tried to locate the same but it is nowhere to be
found and to no avail;

4. That I hereby declare that the said TOP Ticket had been lost and
is beyond recovery;

5. I am executing this Affidavit to attest to the truth of the

foregoing facts and to request the proper authorities to honor the
same.

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

day of August, 2019 in the City of Sorsogon, Philippines.

CHRISTOPHER C. GAJULTOS
Affiant

SUBCRIBED AND SWORN to before me, this 15th day of August,

2019, in the City of Sorsogon, Philippines, affiant exhibiting to me his
government issued PhilHealth ID No. 10-025343112-6 issued by the Philippine
Health Insurance [PhilHealth] with his signature and with a photograph in
likeness.

Doc. No. ____;

Page No.____;
Book No.____: NOTARY PUBLIC
Series of 2019.