Republic of the Philippines)

_______________ ) S.S.

AFFIDAVIT OF LOSS

I, _________________, Filipino, of legal age, and with residence at

___________________________, after being duly sworn to in accordance with law, hereby
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 Driver’s License;

2. Despite diligent search and efforts to locate it, I could not find the same such that
I now believe that it is now lost beyond recovery;

3. Said Driver’s License has not been confiscated by the LTO, Police or other Traffic
Enforcers for any traffic violation.

4. 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 Driver’s License and, in
lieu of the ones that were lost; and for whatever legal purpose it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this __________________

at ___________________.

______________________________
Affiant

SUBSCRIBED AND SWORN to before me in ________________ this

___________________ by the affiant, who has satisfactorily proven his identity to me
through ____________________ issued on ______________ in ____________________, that
he is the same person who personally signed the foregoing affidavit before me and
acknowledged that he executed the same.

Doc. No. ;
Page No. ;
Book No. ;
Series of 2023.