REPUBLIC OF THE PHILIPPINES )

PROVINCE )S.S
CITY OF _________________ )

AFFIDAVIT OF LOSS

I, , Filipino, of legal age, married and a resident of, after having duly sworn
to in accordance with law do hereby depose and state:

1. That I am the owner/holder of a Driver’s License Card issued to me by the

Land Transportation Office (LTO);

2. That sometime on the said Driver’s License Card was lost and missing for
the reason that it fell from my pocket while I am driving my motor vehicle;

3. That I exerted earnest effort to locate the same but to no avail;

4. That I am executing this affidavit for the purpose of informing concern

authorities for such circumstances and for the purpose of issuing to new
Driver’s License Card of Land Transportation Office (LTO);

5. That I am executing this affidavit to attest to the truthfulness of the

foregoing facts and for whatever legal purpose this may serve.

IN WITNESS WHEREOF, I have hereunto set my hands this __ day of

_________ 2015 at __________________.

Affiant

SUBSCRIBED AND SWORN to before me this __ day of ______ 2015 at

_____________.

Doc. No. Notary Public

Page No.
Book No.
Series of 2016