REPUBLIC OF THE PHILIPPINES]

CITY OF BACOLOD ] S.S.

x---------------------x

AFFIDAVIT

I, ________________, Filipino, single, of legal age, with address at

___________ after being duly sworn according to law, hereby depose and state:

1. I have applied for a Driver’s License with the Land Transportation Office, Bacolod
City last ________________;

2. That as such, I was supposed to be issued by said Office with a Driver’s License
Card, unfortunately, the same was not claimed by me because
___________________;

3. That such License was not confiscated by any lawful authority for violation of
traffic laws or regulations;

4. That I am executing this affidavit to attest to the truth and veracity of the
foregoing and to support my application for the issuance of a Driver’s License
Card from the Land Transportation Office, Bacolod City and not to defraud
anybody.

IN WITNESS WHEREOF, I hereby affix my signature this _____________ at

___________________.

___________________________
Affiant

SUBSCRIBED AND SWORN to before me this _____________________ at

__________________, affiant personally appeared before me and exhibited her
government-issued identification card with number ______________ valid until
___________ bearing her photograph and signature.

Doc. No. ____;

Page No. ____;
Book No. ____;
Series of 2022.