REPUBLIC OF THE PHILIPPINES)

CITY OF )
x---------x

AFFIDAVIT OF LOSS

I, Vanya Klarika E. Nuque, Filipino, of legal age, single, and with residence at 29-
A St. Simon Street, St. Charbel Executive Village, Mindanao Avenue, Quezon City,
Philippines, after being duly sworn to in accordance with law, hereby depose and state that:

I am a duly-licensed driver in accordance with pertinent Land Transportation laws,

rules and regulations, and was issued a corresponding Driver's License with number N25-
14-007300 which is valid until 02 February 2022;

Last Friday, 31 August 2018, my purse was stolen while walking to SM Megamall.
My driver’s license was inside my wallet which was also inside the said purse.

The said 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, in lieu of the one
that was lost/stolen.

IN WITNESS WHEREOF, I have hereunto set my hand this 03rd day of September,
2018 at Mandaluyong City, Philippines.

_________________________________
Signature of Affiant over Printed Name

SUBSCRIBED AND SWORN to before me, this 03rd day of September, 2018, in the City
of Mandaluyong by Vanya Klarika E. Nuque with Tin No. TIN-3456-789-0 issued on Feb.
2, 2012 at Quezon City.

Doc. No. ______;

Page No. ______;
Book No. ______;
Series of 2018.