Republic of the Philippines )

____________,____________ ) S.S

KNOW ALL MEN BY THESE PRESENTS:

I, __________ of legal age, Filipino, married, and a resident of

___________________________, after having been sworn in accordance with law, hereby
deposes and states the following:

1. I am the owner and in possession of a Drivers License;

2. I have recently discovered that the said Driver’s license is irretrievably lost and
can no longer be found despite diligent efforts to locate the same;

3. I execute this affidavit to attest to the truth of the foregoing.

Signed on the date and at the place indicated below.

__________________
Affiant

Competent Evidence of Identity

______________________

SUBSCRIBED and SWORN TO before me on the date and at the place indicated
below. The affiant exhibited to me her competent evidence of identity as indicated
above.

Signed this _________________at_____________, ____________, Philippines.

WITNESS MY HAND AND SEAL.

Notary Public

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