AFFIDAVIT OF LOSS

REPUBLIC OF THE PHILIPPINES)

_____________________________ ) S.S.


I, ______________________, Filipino, of legal age, residing a _____________________________,
afer !a"ing #een s$orn in a%%ordan%e $i! la$, !ere#& depose and sae'

T!a I a( !e r)e and la$f)l o$ner of a Non*Professional +ri"er,s Li%ense iss)ed
#& !e Land Transporaion Offi%e $i! Li%ense No. E-.*-/*---0123
T!a so(ei(e on 4)l& of !is &ear, I $as loo5ing for said li%ense #) !e sa(e %o)ld
no longer #e lo%aed, and !)s I !a"e reason o #elie"e !a i !ad disappeared in s)%! a $a&
!a is e6isen%e is )n5no$n or i %anno #e re%o"ered3

T!a I oo5 pains o loo5 for said dri"er,s li%ense, #) o no a"ail3

T!a I a( e6e%)ing !is affida"i o aes o !e r)! of !e foregoing and o re7)es
fro( !e Land Transporaion Offi%e !e iss)an%e of ano!er li%ense in lie) of !a $!i%! I
!a"e los.

IN 8ITNESS 8HEREOF, I !a"e !ere)no se (& !and !is _____ da& of O%o#er, 9-:- a
_________________________.



______________________
;ffian

SUBSCRIBE+ ;N+ S8ORN o #efore (e, !is ____ da& of O%o#er, 9-:- in
______________________, $i! affian e6!i#iing !is CTC No. ____________________, iss)ed on
____________________, 9-:- a <)ino#aan, ;l#a&.


NOTARY PUBLIC


+o%. No. ' ________3
Page No. ' ________3
Boo5 No. ' ________3
Series of 9-:-.