Republic of the Philippines)

City of Tacloban ) S.S.

x---------------------------x

AFFIDAVIT OF LOSS

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

Scandinavian Village, Tacloban, City, after being 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;

(2) That the aforesaid PROFESSIONAL DRIVER’S LICENSE I.D. was lost due to
unavoidable circumstances when it was unfortunately misplaced;

(3) Efforts were exerted to locate said driver’s license, but despite diligent search,
it could not be found and the same is now beyond recovery;

(4) Said Driver’s License has not been confiscated by the LTO, Police or other
Traffic Enforcers for any traffic violation;

(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 __________ in

Tacloban City, Leyte, Philippines

________________________
Affiant
_______________

SUBSCRIBED AND SWORN to before me this ___________ in the City of

Tacloban, Philippines, affiant exhibited to me his __________________as valid proof of
identity.

Doc. No. _____

Page No. _____
Book No. _____
Series of ____