Republic of the Philippines ]

City of Marikina. ] S.S.

AFFIDAVIT OF LOSS OF DRIVERS LICENSE

I, ______________________________, of legal age, Filipino citizen, __________,

residing at ____________________________________________________________,
Philippines, UNDER OATH, do hereby depose and state THAT:

01. I was issued a professional drivers license with no. _____________

by Land Transportation Office (LTO) of ____________ on
_____________________, a copy of which is hereto attached as Annex A/
not available;

02. On ______________________ in _____________________, my said

drivers license was lost and despite efforts exerted I have not recovered the
same;

03. My said drivers license has not been seized or held by any law
enforcement agency for any violation of traffic laws, rules and regulations
or in connection with any crimes or vehicular incidents;

04. I have this affidavit executed to attest to the truth of the foregoing and for
the purpose of reporting to the Land Transportation O0ffice (LTO) the loss
of my said drivers license in order that I can secure a replacement of said
drivers license as well as for other legal purposes this may serve.

IN WITNESS WHEREOF, I have hereunto affixed my signature on this ______ day

of _____________________ in Marikina City, Philippines.

Affiant

SUBSCRIBED AND SWORN to before me on this_____ day of

_________________ in Marikina City, Philippines. Affiant exhibited as evidence of
identity ______________________________________________________

NOTARY PUBLIC

Doc. No. ______;

Page No. ______;
Book No.______;
Series of 20____.