Republic of the Philippines }

Province of Surigao del Sur }

Municipality of Cantilan } S.S.
x--------------------------------------------x

AFFIDAVIT OF LOSS

I, _______________, of legal age, Filipino, with residence at P-3 Orozco St., Magosilom,
Cantilan, Surigao del Sur, having been duly sworn to in accordance with law, do hereby
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 Driver’s License with
number _______________;

2. The 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 Professional
Driver's License, in lieu of the one that was lost;

IN WITNESS WHEREOF, I have hereunto set my hand this 19 th day of May, 2021 at
Cantilan, Surigao del Sur, Philippines.

Affiant

SUBSCRIBED AND SWORN TO before me, this 19th day of May 2021, in the
Municipality of Cantilan, Surigao del Sur, affiant exhibiting to me his Senior Citizen ID as
his Competent Evidence of Identity.

Doc. No.
Page No.
Book No.
Series of 2021.