Republic of the Philippines) Quezon City ) Sc.
AFFIDAVIT OF LOSS
I, JUAN
P. DELA CRUZ, Filipino, of legal age, single and with residence and
postal address at Unit 105 Silver
Place Townhouse, Mango Circle, Quezon
City, after having been duly sworn to in accordance with law, hereby
depose and state that:
1. Sometime in December 18, 2012, I
was looking for my Driver’s License;
AFFIANT
FURTHER SAYETH NAUGHT.
JUAN P. DELA CRUZ
Affiant
IN
WITNESS WHEREOF, I have hereunto set my hand this 23rd day of December 2014 at Quezon, City, Philippines.
JUAN P.
DELA CRUZ
Affiant
JURAT
SUBSCRIBED
AND SWORN to before me this 23rd day of December
2014, affiant personally appeared and exhibited to me his Philippine Passport No. EB-1234567
issued on July 16, 2012 in Manila,
Philippines.
NOTARY PUBLIC
Doc. No.:
_____;
Page No.: _____;
Book No.: _____;
Series of 20_____.
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