REPUBLIC OF THE  PHILIPPINES}

_____________________ } S.S.
x---------------------------------------------------------x

AFFIDAVIT OF LOSS

I, JUAN G. DELA CRUZ, Filipino, of legal age, and with office

address at Unit 207, The Walk Building, Brgy. Sto. Teresa, Morong, Rizal,
after having been sworn in accordance with law, do hereby depose and state
that:

1. I am a holder of LTO Professional/Non-Professional Driver’s

License with No. 12345 (the “Subject ID”), a copy of which is
attached hereto as Annex “A”.
2. On 13 October 2020, however, I noticed that the Subject ID had
been missing from my personal effects and belongings.
3. I exerted diligent efforts to locate the Subject ID but to no avail. I
therefore consider it lost and beyond recovery.
4. I am executing this Affidavit to attest to the truth of the foregoing
facts and for whatever legal purpose it may serve.

IN WITNESS WHEREOF, I hereunto affix my signature this ___

day of ______________ in _______________, Philippines.

JUAN G. DELA CRUZ

Affiant

SUBSCRIBED AND SWORN to before me this ___ day of

______________ in _______________, Philippines, affiant exhibiting to me
his ____________________________ as competent proof of his identity.

WITNESS MY HAND AND SEAL.

Doc No. ____;

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