(Affidavit of Loss - Driver's License)

REPUBLIC OF THE PHILIPPINES)

Province of ____________________) S.S.

City/Municipality of _____________)

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

AFFIDAVIT OF LOSS

I, _____________, Filipino, of legal age, (single / married / widow), and with

residence at _____________, Philippines, after being duly sworn to in accordance with
law, hereby depose and state:

1 That I am a duly-licensed driver in accordance with pertinent Land

Transportation laws, rules and regulations, and was issued a
corresponding Driver's License with number _____________ which is valid
until _____________;

2 That sometime last week, said Driver's License was misplaced and got
lost;

3 That despite diligent search and efforts to locate my Driver's License, I

could not find the same such that I now believe that it is now lost beyond
recovery;

4 That 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 Driver's
License, in lieu of the one that was lost.

IN WITNESS WHEREOF, I have hereunto set my hand this _____________ at

_____________, Philippines.
 AFFIANT

(JURAT)