REPUBLIC OF THE PHILIPPINES )

PROVINCE OF CAMARINES NORTE ) SS.

MUNICIPALITY OF DAET )

AFFIDAVIT OF LOSS

I, ______________________, of legal age, Filipino citizen, and a resident of

______________________________, after being sworn to in accordance with law, hereby
depose and say:

That I am a holder of Professional Driver’s License issued by the Land Transportation

Office (LTO) in _______________________;

That I normally kept said license together with some other pertinent IDs inside my wallet
and I always bring with me the same for reference purposes whenever needed;

That however, sometime on October 7, 2022, my wallet containing said license was lost
and it is likely believed that the same might have slipped off from my pocket while I was driving
a motorcycle in ______________________;

That utmost effort was exerted in trying to retrieve my wallet containing said license, but
to no avail, and now the same is considered lost and cannot be recovered;

That said license was not confiscated by the PNP/LTO or any law enforcement authority
nor involved in any accident/traffic violation, but the same was lost in the manner stated above;

That I am executing this affidavit to attest to the veracity of the foregoing facts to request
the Land Transportation Office (LTO) in _______________________ to issue in my favor a new
driver’s license in lieu of the lost one and for whatever legal purpose this may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this 18th day of October, 2022,
in _______________________.

_____________________
Affiant

SUBSCRIBED AND SWORN to before me this 18th day of October, 2022, in Daet,
Camarines Norte.

Doc. No._____
Page No._____
Book No._____
Series of 2022.