REPUBLIC OF THE PHILIPPINES]

CITY of _____________________]S.S.

AFFIDAVIT OF LOSS

I, PROSPERO C. CRUZ., of legal age, Filipino and with residence address

at Lot 42 Block 1, Apple St., Phase 10-E, Greenland Village, Brgy. San Andres,
Pasig City, after being duly sworn to in accordance with law, hereby depose and
state that:

1. I applied for the renewal of my Professional Driver’s License at the Land

Transportation Office (LTO) Driver’s License Renewal Center (DLRC) in
Robinson’s Galleria in Mandaluyong City on 14 June 2017;

2. I was not yet issued at the time my renewed Driver’s License card
because there was no available card yet;

3. Nonetheless, I was issued LTO’s Official Receipt or O.R. with number

098765431 dated 14 June 2017;

4. In the last week of October 2017, being a seafarer by profession, I was

again deployed for work aboard an ocean-going vessel under a 10-month contract;

5. After getting back to the country just recently, I sought to claim my

Driver’s License Card from Robinson’s DLRC with the presentation of the
aforementioned LTO O.R.;

6. Unfortunately, despite diligent search in my residence address and in

our Manning Agency, I could no longer find or locate the original copy of the LTO
O.R. with No. 098765431 which might have been misplaced;

7. I am executing this Affidavit to attest to the truth of the foregoing and for
the purpose of obtaining from the proper office of the LTO a duplicate copy of the
lost LTO O.R. which must accompany a person’s Driver’s License all the time while
operating a motor vehicle.

FURTHER AFFIANT SAYETH NAUGHT.

PROSPERO C. CRUZ
Affiant

SUBSCRIBED AND SWORN TO before me this ____________________, in

________________________, Philippines, affiant exhibiting to me his SSS Identification Card with No. 33-
12345678-1.

Doc. No. ________;

Page No.________;
Book No.________;
Series of 2019.