REPUBLIC OF THE PHILIPPINES )

QUEZON CITY ) S.S.

AFFIDAVIT OF LOSS

I, CZAR NICKLAUS PARK, of legal age, Filipino, married and a

resident of SVD Road, Tagaytay City after having been duly sworn to in
accordance with law, depose and state THAT:

1. Sometime in April 2017, my wallet got lost together with my

Identification Cards and Driver’s License;

2. Efforts were exerted to locate the wallet, IDs and Driver’s License, but
in spite of diligent search, they could not be found and the same is now
beyond recovery;

3. Said Driver’s License have not been confiscated by any government

agency, Police or other Law Enforcers for any violation;

4. 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 ones that were lost;

IN WITNESS WHEREOF, I have hereunto set my hand this ____ of

April 2017 in _______________, Philippines.

CZAR NICKLAUS PARK

Affiant

SUBCRIBED AND SWORN TO before me this ____of April 2017 in

_______________________, Philippines, affiant exhibiting to me
ID__________________________as proof of identity.

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 2017.