REPUBLIC OF THE PHILIPPINES)

_____________________ ) S.S.

AFFIDAVIT OF LOSS

I, XXX, of legal age, married, Filipino, and a resident of XXX, after having
been duly sworn to in accordance with law, hereby depose and state, that:

1. I am a holder of a Driver’s License issued by the Land Transportation Office;

2. I placed the said driver’s license inside my wallet together with all other
identification cards.
3. Sometime in September 22, 2019 at around 10:00 o’clock in the morning, I
boarded a tricycle and went to Science City of Munoz, Nueva Ecija as I attend
to some personal matters. When I was done with my errands, I was at the
public market of Science City of Munoz, Nueva Ecija when I noticed that my
wallet containing my Driver’s License among others, is already missing from
the back pocket of my pants which most probably fell off while I was attending
to with my errands;
4. I exerted diligent efforts to locate the same but my efforts proved futile as the
same could no longer be found;
5. I am executing this affidavit to attest to the truth of all the foregoing statements,
for purposes of attesting to the facts and circumstances surrounding the loss of
my Driver’s License, to seek for a replacement for the same and for all legal
intents and purposes this may serve.

IN TRUTH WHEREOF, I have hereunto affixed my signature this

_____________________ in ___________________.

XXX
Affiant

SUBSCRIBED AND SWORN TO before me this ___________________ in

_________________, affiant exhibiting to me his competent evidence of identity.

Doc. No.________
Page No.________
Book No.________
Series of 2019