R Republic of the Philippines)

City of Iligan . . . . . . . . . . . . )Sc.

Affidavit of Loss
I, ____________, of legal age, Filipino, and a resident of __________________, after
having duly sworn to an oath as required by law, hereby depose and say:

1] That I used to be a holder a Driver’s License Card issued by the Land

Transportation Office, ______;

2] That on this date, around 7:00 o’clock in the morning while reporting to
duty from ______ to _______ on board with our service truck, and upon reaching
said destination, I was dismayed to discover that my wallet containing my driver’s
license, was lost which I believe the same may have fallen out from my pocket;

3] That earnest effort was exerted to locate said driver’s license but no to
avail and is now beyond grasp for all intents;

4] That the said loss of my driver’s license was never lent to another
person or entity nor confiscated by any other law enforcement agency;

5] That I bind myself to surrender the said driver’s license to the district
office that issued the same in the event that said card is recover;

6] That the purposes of this affidavit of loss is for securing a replacement

for the loss of my driver’s license;

7] That I am executing this affidavit for the aforesaid purpose as well as

for attesting to the truth of the statements herein declared, subject to the rules on
perjury.

IN WITNESS WHEREOF, I have hereunto set my hand this _____ at ________.

___________________
Affiant

SUBSCRIBED AND SWORN to before me this 5th day of October 2022 at ______
Philippines. Affiant is personally known to me and she has satisfactorily proven to me her
identity through his credentials.

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