REPUBLIC OF THE PHILIPPINES )

_____________________…………) s.s.

AFFIDAVIT OF LOSS
I, ___________________, of legal age, married, Filipino Citizen and a
resident of _____________________, Philippines, under oath, declare and state
that:

1. I was issued a Driver’s License but the same was confiscated by the
Land Transportation Office (LTO) for absence of warning device;

2. After the said license was confiscated, I was issued a Temporary

Operator’s Permit (TOP) which I kept in my wallet along with other
identification cards and personal documents;

3. Sometime last Tuesday, 21 May 2019, upon arriving at my residence,

I was surprised to find out that my wallet where I put the issued TOP
was missing and nowhere to be found;

4. I wielded all efforts to locate the said TOP but all my efforts proved
futile and in vain which made me conclude that the same is forever
lost and beyond recovery for all legal intents and purposes;

5. I am executing this affidavit to report the loss of the said TOP;

6. Finally, I am executing this affidavit to attest to the veracity of all the

foregoing statements and for all legal intents and purposes it may well
serve.

IN WITNESS WHEREOF, I have hereunto affixed my signature this _____

day of __________ in __________________, Philippines.

_________________
Affiant

SUBSCRIBED AND SWORN TO before me this _____ day of __________

in __________________, Philippines.

Doc No.
Page No. ____________________________
Book No. Notary Public until _______
Series of