REPUBLIC OF THE PHILIPPINES )

PROVINCE OF QUEZON ) S.S.

AFFIDAVIT OF LOSS

I, _____________________________ of legal age, Filipino citizen and with

residential address at Brgy. Domoit, Lucena City, Province of Quezon, after having been
sworn to in accordance with law, hereby depose and state;

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 September 08, 2023;

Sometime on December 2023, said driver's license was misplaced and got lost;

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;

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

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;

That I am executing this affidavit in order to attest to the truth of the foregoing
facts and circumstances and for whatever legal purpose this may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this December 22,

2023 in Lucena City, Philippines.

________________________________
Affiant

SUBSCRIBED AND SWORN to before a Notary Public for and in the Province
of Quezon, this 23rd day of October 2023, affiant personally appeared and exhibited to me
her government issued identification card with ID with No. _______________________
as competent proof of her identity.

Doc. No. ___ `

Page No.___
Book No.___
Series of 2023