Affidavit of Loss

Republic of the Philippines      )

Province of Pampanga             ) s.s.

CITY OF MABALACAT        )

AFFIDAVIT OF LOSS

KNOW ALL MEN BY THESE PRESENTS:

I, _________________, Filipino, single, twenty-four years old, and a resident of 69 st., B-82, L-08, Mauaque Resettlement Center, Sapang Biabas, Mabalacat City, Pampanga after having been sworn in

accordance with law, hereby deposes and states the following:

1. That I am holder official receipt of a student driver's license which I usually place in my bag;

2. That sometime on March 2017, I lost my bag and with it the official receipt of a student driver's license;

3. That despite diligent efforts to locate it, I am unable to find it, I firmly believed that the said official receipt of a student driver's license is now lost or it cannot be recovered;

4. I execute this affidavit to attest to the truth of the foregoing to the best of my knowledge and belief.

IN WITNESS WHEREOF, I signed this Affidavit of Loss as of the date set forth below.

______________________________________

Affiant

ID: _________________

Issued at:_____________

Valid until:____________

SUBSCRIBED and SWORN TO before me on the date and at the place indicated below. The

affiant exhibited to me his competent evidence of identity as indicated above.

Signed this ______________at ________________, ______________________, Philippines.

WITNESS MY HAND AND SEAL.

Notary Public

Doc. No._____

Page No._____

Book No._____

Series of _____