Republic of the Philippines)

Province of _______________) S.S.

x - - - - - - - - - - - - - - - - - - - - - - - x
Affidavit of Loss Drivers License
I, ___________________, Filipino, of legal age, (single/arrie!/"i!o"/"i!o"er),
an! "ith resi!ence at ____________________________, Philippines, after being
!ul# s"orn to in accor!ance "ith la", hereb# !epose an! state$
%. &hat I a a !ul#-license! non-professional !river in accor!ance "ith
pertinent '()* &R()SP+R&(&I+) '(,S, R-'.S ()*
R./-'(&I+)S, an! "as issue! a correspon!ing *river0s 'icense "ith
nuber _____________ "hich is vali! until _____________1
2. &hat three(3) !a#s ago, sai! *river0s 'icense "as isplace! an! got
lost1
3. &hat !espite !iligent search an! efforts to locate # *river0s 'icense, I
coul! not fin! the sae such that I no" have reasons to believe that it is
no" lost an! can4t be recover1
5. &hat sai! *river0s 'icense has not been confiscate! b# the '&+, Police
or other &raffic .nforcers for an# traffic violation1
6. (s such, I a executing this (ffi!avit of 'oss to attest to the truth of the
foregoing an! to support # application for the issuance of a ne" *river0s
'icense, in lieu of the one that "as lost.
I) ,I&).SS ,7.R.+F, I have hereunto set # han! this _____________ at
_____________, Philippines.
___________(signature)___________
(FFI()&
SUBSCRIBED AND SWORN TO BEFORE ME, a notary public in and for
!City"#ro$inc%& t'i( t' day of )*+
Affiant p%r(onally ca,% and app%ar%d -it' !Co,p%t%nt E$id%nc% of
Id%ntity& i((u%d by t'% !.o$%rn,%nt A/%ncy& on !dat%&
at !plac%&, b%arin/ 'i( p'oto/rap' and (i/natur%, 0no-n to ,% a( t'%
(a,% p%r(on -'o p%r(onally (i/n%d t'% for%/oin/ in(tru,%nt b%for% ,% and a$o-%d
und%r p%nalty of la- to t'% -'ol% trut' of t'% cont%nt( of (aid in(tru,%nt+
Atty
Notary #ublic
Doc+ No+ Co,,i((ion S%rial No+
#a/% No+ Notary #ublic for !#ro$inc%"City&
Boo0 No+ Until D%c%,b%r 12, )*
S%ri%( of )* Offic%3 !addr%((&
Roll No+
IB# 4if%ti,% Roll No+ 5 "" 5 !#ro$inc%&
#TR No+ 5 "" 5 !#ro$inc%&
MC4E Co,plianc% C%rt+ No+ 5 ""