REPUBLIC OF THE PHILIPPINES}

CITY OF ______________________ } S. S.

AFFIDAVIT

I, ______________________________, of legal age, single and residing at

__________________________________________, after being duly sworn hereby
depose and say that:

1. I possessed a Driver’s License issued by the _______________ District Office

of the Land Transportation Office located at MacArthur Highway, Brgy.
Santo Domingo, Angeles City, Pampanga, sometime in ___________;

2. On July 26, 2014, above-mentioned Driver’s License together with other

valuables in my wallet went missing and probably slipped out of my pocket
while I was commuting.

3. After an extensive and inexhaustible search, I could not locate nor find the
wallet including the above-mentioned Driver’s License;

4. I have executed this affidavit for the purpose of applying for a replacement of
the lost Driver’s License above-mentioned.

IN WITNESS WHEREOF, I have set my hand this, 27th day of July 2014, at
Binan City, Laguna, Philippines.

_______________________
Affiant

JURAT

SUBSCRIBED AND SWORN to before me, this ____th day of July 2014,
affiant exhibiting his ________ ID No. ___________________, issued at
_________________, on ________________.

___________________
Notary Public
Until December ______

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 2014.