(Affidavit of Loss Drivers License)

Republic of the Philippines)

Province of ____________________) S.S.

City/Municipality of _____________)

x---------x

AFFIDAVIT OF LOSS

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.
AFFIANT

(JURAT)