(single/married/widow/widower), 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 non-professional 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 three(3) days ago, 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 have reasons to believe that it is now lost and can’t be recover;
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.
___________(signature)___________ AFFIANT
SUBSCRIBED AND SWORN TO BEFORE ME, a notary public in and for
_________(City/Province)____________ this ____th day of ____________ 20___. Affiant personally came and appeared with _____________(Competent Evidence of Identity)______ issued by the _________(Government Agency)______ on ___(date)__ at ________(place)_________, bearing his photograph and signature, known to me as the same person who personally signed the foregoing instrument before me and avowed under penalty of law to the whole truth of the contents of said instrument. Atty _______________________________________ Notary Public Doc. No. ____ Commission Serial No. __________________ Page No. ____ Notary Public for _______(Province/City)_____ Book No. ____ Until December 31, 20__ Series of 20__ Office: ______________(address)__________ Roll No. __________ IBP Lifetime Roll No. ________; __/__/__ ; (Province) PTR No. _________ ; __/__/__ ; _(Province)_ MCLE Compliance Cert. No. __________; __/__/__ [13upCD]