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
________________________________ which is valid until
________________________;

2. Sometime on ______________________ the said driver's license was been

confiscated by the LTO Officer;

3. On _________________ at around -______________, 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 ______ day of

_________________Paniqui, Tarlac, Philippines.

Affiant

SUBCRIBED AND SWORN TO before me this _________ day of

__________________ Paniqui, Tarlac, Philippines.

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 20___