REPUBLIC OF THE PHILIPPINES)

Province Of Camarines Sur ) S.S.

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

AFFIDAVIT OF LOSS

I, ___________________, of legal age, Filipino, (single/married/widow) and a resident of

_______________________________, after having been duly sworn to in accordance with law,
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 (Non) Professional Driver's License
with number _____________ which is valid until _____________;

2. Sometime on ____________, said driver's license was misplaced and got lost;

3. Efforts were exerted to locate said driver's license, but in spite of diligent search, it could not be
found and the same is now beyond recovery;

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

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 issuance of a new (Non) Professional Driver's License, in lieu of the one
that was lost;

IN WITNESS WHEREOF, I have hereunto set my hand this ___________________ in

Makati City, Metro Manila, Philippines.

____________________
Affiant
ID No. _____________

SUBCRIBED AND SWORN TO before me this ___________________ in

_________________, Philippines, affiant exhibiting to me his/her competent evidence of identity
by way of __________________ issued at ______________ on __________________.

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 2013.