Affidavit of Loss

1. Republic of the Philippines
Province of CAMARINES NORTE
S.S.
City/Municipality of DAET
x - - - - - - - - - - - x
AFFIDAVIT OF LOSS
I, ARIEL RINON MAGANA JR, Filipino, of legal age, married, and a
resident of 3072 Purok 3 Brgy. Gahonon, Daet Camarines Norte Philippines,
after being duly sworn to in accordance with law, hereby depose and state:
That I am a Public School Elementary Teacher at San Isidro Elementary School,
Jose Panganiban, Camarines Norte, Philippines and at the same time a duly-
licensed driver (Professional);
That on____________at around________,while I was at
the____________at_____________, I lost my wallet which I usually place in my
back pocket.
That inside the said wallet are my Driver's License and ATM Card issued
by_____________ Bank,____________Branch
That despite diligent search and efforts to locate the said wallet and my Driver's
License and my ATM Card, I could not find them such that I now believe that they
are now lost beyond recovery
That my Driver's License has not been confiscated by the LTO, Police or other
Traffic Enforcers for any traffic violation.
As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
and to support my application for the issuance of a new Driver's License and a new
ATM Card, in lieu of the ones that were lost.
IN WITNESS WHEREOF, I have hereunto set my hand
this_____________at_____________, Philippines.
Affiant