REPUBLIC OF THE 

PHILIPPINES)

CITY OF CABANATUAN             ) S.S.

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

AFFIDAVIT OF LOSS

I, _____________________, of legal age, Filipino, single, with postal address at

__________________, after having been duly sworn to in accordance with law, depose and
state that:

1. I am a holder of a Professional Driver’s License Identification Card bearing License No.

____________________, issued by Department of Land Transportation Office (LTO);

2. I have always kept the said Driver’s License in my personal wallet for safety and easy
access;

2. Sometime in December 19, 2022, when I arrive home from work, I discovered that my
wallet containing my driver’s license was missing.

3. I tried to locate said wallet, however, despite diligent search and efforts to locate said
wallet, I could not find it;

3. The said Driver’s License was not confiscated by the authorities by reason of any
violation of LTO’s rules and regulations;

4. I am executing this affidavit to attest to the truth of the foregoing facts and to request for a
replacement of said company Driver’s License from Land Transportation Office.

______________________
Affiant

SUBSCRIBED AND SWORN to before me this 22nd day of December, 2022 in the
_________________. Affiant exhibited to me her ______________ issued at
_________________.

Doc. No. ____;

Page No. ___;
Book No. ___;
Series of ___.