REPUBLIC OF THE PHILIPPINES)

PROVINCE OF TARLAC ) S.S.

MUNICIPALITY OF PANIQUI )
x----------------------------x

AFFIDAVIT OF LOSS

I, __________________ of legal age, Filipino and a resident at

__________________________, 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 Professional Driver's License with License No.
_____________________ which is valid until ___________________;

2. Sometime on September 12, 2019 the said driver's license was been
confiscated by the LTO Officer;

3. On September 12, 2019 at around 3:30pm, when I was about to claim

the said Driver’s License, it was unintentionally misplaced/lost by the LTO
Officer;

4. Efforts were exerted to locate said driver's license, but in spite of diligent
search, it could not be found and the same is now beyond recovery;

5. 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
Professional Driver's License, in lieu of the one that was lost;

IN WITNESS WHEREOF, I have hereunto set my hand this 13th day of

September 2019 Paniqui, Tarlac, Philippines.

_________________________.
Affiant

SUBCRIBED AND SWORN TO before me this 13th day of September 2019

Paniqui, Tarlac, Philippines.

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 2019.