Republic of the Philippines )

City of ___________ ) S.S.

AFFIDAVIT OF LOSS

I, [NAME OF AFFIANT], of legal age, Filipino, single and with address at Billiar
Drive, Baliwasan, Zamboanga City, after having duly sworn in accordance with law, hereby
depose and state that:

1. I am a holder of a Non-Professional Driver’s License duly issued by the Land

Transportation Office of ______________ City. The aforesaid driver’s license is
kept inside my bag, together with my other personal belongings.

2. On [Date], I went around town to run some errands and had dinner with my
friends. However, upon arriving home. I found out that the my driver’s license
was missing. I believed that it must have fallen while I was on my way home from
town;

3. I have exerted all my efforts to locate the same but to no avail.

4. I am executing this affidavit to attest the truth of the foregoing facts and for such
other legal purposes this affidavit may serve.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

_______ 2023 in the City of __________.

[NAME OF AFFIANT]
Affiant

SUBSCRIBED AND SWORN, to before me this ___ day of July 2023 in the City of
________, affiant exhibiting to me his PRC ID bearing numbers ________ duly issued by
the Professional Regulation Commission valid until _____________.

NOTARY PUBLIC