REPUBLIC OF THE PHILIPPINES)

PROVINCE OF ALBAY ) S.S.

TABACO CITY )
x------------------------------------------x

AFFIDAVIT OF LOSS

I, ___________________, of legal age, Filipino, (single/married/widow) and a resident

of _______________________________, after having been duly sworn to in
accordance with law, 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 (Non) Professional Driver's
License with number _____________ which is valid until _____________;

2. Sometime on ____________, 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 (Non) Professional Driver's License,
in lieu of the one that was lost;

IN WITNESS WHEREOF, I have hereunto set my hand this ____ day of ___________
20____ in ____________, _____________, Philippines.

___________________________________

Affiant

SSS ID No. _____________

SUBSCRIBED AND SWORN to before me, this ____ day of __________ 20____, in
the City of __________________, by ___________________ with Passport
No.________________ issued on __________________ at _____________.

ATTY. ANTHONY CLARK A. GAPIDO

Notary Public Tabaco City
For the Province of Albay
Roll No. 83746
IBP OR No. 227570; June 13, 2022
PTR No. 8843533; July 13, 2022 at Tabaco City
MCLE: N/A (Newly Admitted to the Bar)
2nd Floor Coastal Building Rental, Purok 2,
Morales Street, San Roque,Tabaco City, 4511
Doc No.____;
Page No. 450;
Book No. 35 ;
Series of 2022