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REPUBLIC OF THE PHILIPPINES)

CITY OF COTABATO ) SS.

AFFIDAVIT OF LOSS

I, Samir Bangon Mamulintao, Filipino, single, of legal age, residing at Bagua


2, Cotabato City after having been sworn to in accordance with law hereby depose and
state that:

1. I am the owner of a Driver’s License issued by LTO Cotabato City;

2. I kept the said license to my wallet;

3. Yesterday, March 11, 2019, while driving I suddenly lost it.

4. After diligent search, elsewhere, the said receipt was nowhere to be found
anymore;

5. I am executing this affidavit in order to attest to the truth of the foregoing


circumstances and for the purpose of informing the LTO Cotabato City about
the loss of my driver’s license.

IN WITNESS WHEREOF, I hereby affix my signature this 12th day of March 2019
in Cotabato City.

Samir Bangon Mamulintao


Affiant

SUBSCRIBED AND SWORN to before me, a Notary Public, this 12th day of
March 2019 at Cotabato City, affiant personally known to me.

Doc. No. ;
Page No. ;
Book No. ;
Series of 2019.