REPUBLIC OF THE PHILIPPINES)

City of Imus ) S.S.

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

AFFIDAVIT OF LOSS

I, ___________________________, Filipino, of legal age and with an address at

________________________________________, after being duly sworn to in
accordance with law, hereby depose and state that:

1. I am the Owner of a Driver License with a license no._________________;

2. I usually bring my license and keep it on my wallet;

3. On ___________ I gave my license to _____________ for safekeeping since

we are at a event before the said date;

4. Upon going home my ___________ on the tricycle that _____________. I

tried to look for the tricycle that _________________________. I cannot
anymore locate it up to the present. I now believe it is already lost and
beyond recovery;

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 re-issuance of driver’s
license at __________________________.

IN WITNESS WHEREOF, I have hereunto set my hand this _______ at

__________, Philippines.

_____________________________________________
Affiant

SUBSCRIBED AND SWORN to before me at the place and date above

stated. I hereby certify that I personally examined the affiant and am convinced that
she voluntarily executed the foregoing affidavit, read the same and understood it
contents.

Doc. No. ______; NOTARY PUBLIC

Page No. ______;
Book No.______;
Series of 20__