REPUBLIC OF THE PHILIPPINES )

CITY OF ________ ) S.S.

AFFIDAVIT OF LOSS

I, _________________, Filipino, of legal age, single, and resident of

__________________, after having been duly sworn in accordance with
law, hereby depose and state that:

1. I am the registered owner of a valid and existing Driver’s License,

the last renewal of which was made at the Land Transportation Office (LTO)
Branch in __________.

2. On or about ____________, I lost the above Driver’s License

somewhere in ________________.

3. Despite diligent efforts, I could no longer locate, find or recover

the said Driver’s License, and to the best of my knowledge, the same is truly
lost and beyond recovery.

4. The said Driver’s License has not been confiscated by any officer
of the law or the issuing office or agency due to the violation of any law,
statute, order, rule or regulation.

5. In the event that the lost Driver’s License should hereafter be

found or located, I undertake to forward or surrender the same to the Land
Transportation Office (LTO) for appropriate disposal.

6. I am executing this Affidavit to attest to the truth of the foregoing,

to request the issuance of a new Driver’s License in lieu of the one which
was lost, and for whatever legal purpose it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this

_________ at the City of _________.
 ________________________
Affiant

SUBSCRIBED AND SWORN to before me this ____ day of

________ at _____________ by the affiant with Passport No.
_______________ issued by ________________ on ______________ and
valid until _______________.

Notary Public

Doc. No. ____;

Page No. ____;
Book No. ____;
Series of ____.