Republic of the Philippines )

Legazpi City ) S.S.

AFFIDAVIT OF LOSS
KNOW ALL MEN BY THESE PRESENTS:

I, PATRICK JOSEPH IMPERIAL ESTILLOMO, of legal age, Filipino, single, and a resident of
CALAYUCAY, STO. DOMINGO, ALBAY, after having been sworn in accordance with law,
hereby depose and state the following:

1. I am the owner of the OFFICIAL RECEIPT of the Philippine Drivers License Card No.
E02-15-002205;
2. I have recently discovered that the said item is irretrievably lost and can no longer
be found despite diligent efforts to locate the same;
3. I execute this affidavit to attest the truth of the foregoing.

Signed on the date and at the place indicated below.

PATRICK JOSEPH IMPERIAL ESTILLOMO

Affiant
Competent Evidence of Identity
ID: Non-professional Driver’s License No. E02-15-002205

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. _____
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