REPUBLIC OF THE PHILIPPINES ) CITY OF ILOILO ) S.S.

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: 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 _____________; That sometime last week, said Driver's License was misplaced and got lost; 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; That 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 Driver's License, in lieu of the one that was lost. IN WITNESS WHEREOF, I have hereunto signed this ____ day _____________, 2012, at Iloilo, Philippines _____________________ Affiant CTC No. Issued at Issued On Valid ID NO. Valid until
SUBSCRIBED AND SWORN to before me, this ____ day of ______________, 20___ in ___________________ City, with affiant exhibiting his CTC No. _______________ , Issued on ______________________ at _________________________. NOTARY PUBLIC Until December 31, 200___ Doc. No. : ________; Page No. : ________; Book No. : ________; Series of 20___.