Republic of the Philippines) Province of _______________) S.S.

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-Affidavit of Loss Drivers License I, _____________, Filipino, of legal age, (single / married / widow), and with residence at _____________, 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 _____________ which is valid until _____________; That sometime last week, said Driver's License was misplaced and got lost; That despite diligent search and efforts to locate my Driver's License, I could not find the same such that I now believe that it is now lost beyond recovery; That 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.

IN WITNESS WHEREOF, I have hereunto set my hand this _____________ at _____________, Philippines.

_________________________________ (Signature of Affiant over Printed Name)

date of issue.Jurat REPUBLIC OF THE PHILIPPINES) PROVINCE OF _______________) CITY/MUNICIPALITY OF ______ ) S. SUBSCRIBED AND SWORN to before me. Series of 2011 . No. Page No. Book NO. date of issue. the affiant exhibiting to me his (any competent evidence of identity) issued by (issuing agency) on (date of issue) at (place of issue). 20011. _____. ____ PTR no. 2010 Roll no. place of issue Office Address: Email: Contact Number: Doc. ____.S. ____ Until December 31._____. ____. this ____ day of ____.____. place of issue IBP no. in the municipality/ city of_____. NOTARY PUBLICAppointment No.

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