Republic of the Philippines) SS

City of _______ . . . . . . . . )

AFFIDAVIT OF LOSS

I, (name), of legal age, Filipino, single/married, and a resident of (address),

after having been sworn to under oath hereby state, that:

1. I was duly issued a Professional Driver’s License by ___City - Land

Transportation Office;

2. Sometime on __ 20__, while I was in ____ City, I noticed that my driver’s

license was missing as it was no longer inside my bag where I keep it,
nonetheless, I exerted efforts to locate the same by looking for it but despite
my efforts to locate the same, I still did not find my driver’s license which I
suspect that I may have dropped it, hence, I have considered the said license
to have been lost beyond recovery;

3. My aforesaid driver’s license was neither confiscated by the authorities nor

was it used for unlawful purpose;

4. This Affidavit is hereby executed to attest to the truthfulness of the foregoing

and to support my application for a new copy of my said driver’s license and
for all legal intents and purposes it may serve.

Signed this __th day of __20__, ___, Philippines.

_________
Affiant
_____ ID CARD No.__________

BEFORE ME, a Notary Public for and in the City of _______, personally appeared
the affiant who is personally known to me and to me known to be the same person who
executed the foregoing.

WITNESS MY HAND AND SEAL this ___th of ______ at ______City,

Philippines.

Administering Officer