REPUBLIC OF THE PHILIPPINES )

CITY OF __________________) S.S.

AUTHORIZATION AFFIDAVIT

I, , of legal age, Filipino Citizen and a resident of , under oath, states

that:

1. I am the owner of the Driving License Receipt issued by LTO (Branch) with a serial
number ___________.
2. On or about __________, I discovered the loss my Driving License Receipt while
(state circumstances).
3. Despite my diligent efforts, I could not find my Driving License Receipt which led
me to believe that I have truly lost the same.
4. I am executing this affidavit for the purpose of securing the duplicate copy of my
driving license receipt renewed last August 2018 and for any other legal purposes
it may serve.
5. I am executing this affidavit to attest to the truth of the foregoing statements.

Signed this day of _______ at __________.

Affiant

SUBSCRIBED and SWORN TO before me on the date and at the place indicated below.
The affiant exhibited to me his (ID with ID number) as her competent evidence of identity.
Signed this ______________at ________________,
______________________, Philippines.

WITNESS MY HAND AND SEAL.

Notary Public

Doc. No. ____

Page No. ____
Book No. ____
Series of ____