REPUBLIC OF THE PHILIPPINES)

PROVINCE OF ZAMBOANGA DEL NORTE)

CITY OF DIPOLOG ) S.S.
x----------------------------x
  

AFFIDAVIT OF LOSS

 I, CHRISTIAN C. HENSON, of legal age, Filipino, (single/married/widow) and

a resident of STA. ISABEL, DIPOLOG CITY, 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
Non-Professional Driver's License with number 123456 which is valid until
3/21/2022;

2. Sometime on SEPTMBER 16, 2020, said driver's license was misplaced

and got lost;

3. 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;

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 Non-
Professional Driver's License, in lieu of the one that was lost;

IN WITNESS WHEREOF, I have hereunto set my hand this 16TH DAY

OF SEPTEMBER, 2020 in Dipolog City, Zamboanga del Norte, Philippines.

CHRISTIAN C. HENSON
Affiant
SSS ID No. 123456
 SUBCRIBED AND SWORN TO before me this 16TH DAY OF SEPTEMBER,
2020 in DIPOLOG CITY, Philippines, affiant exhibiting to me his/her
competent evidence of identity by way of SSS ID issued at DIPOLOG CITY
on 5/31/2018.

JUAN DELA CRUZ 

NOTARY PUBLIC- Dipolog City 
Appointment No. 1234
Until December 31, 2020
Roll no. 123456 
PTR no. 1234, 1/1/20, Dipolog City 
IBP no.1234, 1/2/20, Dipolog City 
Office Address: Cruz Bldg. Dipolog City
Email: juandelacruzlaw@gmail.com
Contact Number: +639171668148

Doc. No. _____;

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