Republic of the Philippines ))

City of Davao
))
x-------------------------------x

AFFIDAVIT OF LOSS
I, ____________________, of legal age, Filipino, single, and a resident of
Cadena de Amor St., 71-A Agdao Beach Village, Agdao, Davao
City, after having been duly sworn to in accordance with law, depose and
state THAT:
1. I am a duly-licensed driver in accordance with pertinent Land Transportation
laws, rules and regulations, and was issued a corresponding Driver's License
number ____________
2. Sometime on ___________, I went to the Land Transportation Office (LTO) to
renew my Drivers License;
3. Afterwhich, I was issued with an official receipt evidencing such transaction. I
kept the official receipt inside my wallet since I was made to come back the
next day to retrieve my new license;
4. However, the wallet where the said official receipt was kept got lost;
5. Efforts were exerted to locate said document, but in spite of diligent search,
it could not be found and the same is now beyond recovery;
6. As such, I am executing this Affidavit of Loss to attest to the truth of the
foregoing facts.
IN WITNESS WHEREOF, I have hereunto set my hand this ______ in
______City, Philippines.
____________________
Affiant

SUBCRIBED AND SWORN TO before me this ______ in ______City,

Philippines, affiant exhibiting to me his/her competent evidence of identity.
Doc. No. _____;
Page No. _____;
Book No. _____;
Series of 2015.