Republic of the Philippines )

Quezon City ) S.S.

AFFIDAVIT OF LOSS

I, INSERT YOUR LEGAL FULL NAME HERE, Filipino, of legal age, and
presently residing at 123 Lakandula St., Brgy. Dagohoy, Manila City, Philippines, after
having been duly sworn in accordance with law hereby depose and state that:

1. That my Professional Regulation Commission (PRC) Professional Identification Card

has been missing since 1st of January 2020;
2. That despite exhaustive and diligent efforts on my part, the aforementioned PRC ID
can no longer be found and located;
3. That I am executing this affidavit to attest to the truth of the foregoing facts and for
whatever legal purpose this may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this 5th day of January 2020
in Manila City, Metro Manila, Philippines.

JUAN DELA CRUZ

Affiant

SUBSCRIBED AND SWORN to before me this 5th day of January 2020 in Manila
City, Philippines affiant exhibiting to me his LTO Driver’s License No. N00-12-345678.

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 2020