REPUBLIC OF THE PHILIPPINES )

CITY OF DAPITAN ) S.S.

AFFIDAVIT OF LOSS

I, (Name of Affiant), of Legal Age, Filipino citizen, , born on with residential

address at (Address of the Affiant), subscribing under oath,hereby depose
and state that;

1. I am a holder of a Professional Driver’s License Card;

2. On (Date: xx/xx/xx) while on my way to (Dipolog City) with my

personal vehicle, my wallet containing the said License Card, cash and
some personal documents was gone.

3. Despite diligent efforts, I failed to locate the said missing items up to

the present. I now consider them irretrievably lost;

4. I am executing this affidavit to attest to the truth of all forgoing and in

order to support my application to replace the lost one.

BEFORE ME, appears the person of (Name of the Affiant) presenting

the above Affidavit, who is personally known to me or identified by me
through competent evidence of identity as defined by the Notarial Rules as
the person who signs the documents, and in my presence taken an oath or
affirmation before me as to such document.

(Name of the Affiant)

Affiant

WITNESS MY HAND AND SEAL this (nth) day of (month, year) in

Dapitan City, Province of Zamboanga Del Norte.

Doc. No. (xxxxxx);

Page No. (xxxxxx);
Book No. (xxxxxx);
Series of (xxxxxx);

Affidavit
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