REPUBLIC OF THE PHILIPPINES)

CALOOCAN CITY ) S.S.

AFFIDAVIT OF LOSS

I, , Filipino, of legal age, married, and with residence address at, after
being duly sworn to in accordance with law, hereby depose and state:

1. That I was issued a Professional Driver’s License by the Land

Transportation Office under my name with License No.;

2. That on March 10, 2021, the said Driver’s License got lost while I
was at the Social Security System – Deparo branch;

3. That despite diligent search and efforts to locate my Driver’s

License, I could not find the same such that I now have reasons to believe that it
is now lost and cannot be recovered;

4. My Driver’s License has not been confiscated by any government

agency;

5. As such, I am executing this Affidavit of Loss to attest to the truth of

the foregoing and for whatever legal purpose this may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this ___ day of

___________, 2021, in Caloocan City.

Affiant

SUBSCRIBED AND SWORN TO BEFORE ME, a Notary Public for and

in ______________, this __ day of _________, 2021, affiant personally came and
appeared with as his competent proof of identity, bearing his photograph and
signature, and known to me as the same person who personally signed the
foregoing instrument before me and avowed under penalty of law to the whole
truth of the contents of the said instrument.

Doc. No. __;

Page No. __;
Book No. __;
Series of 2021.