Republic of the Philippines)

Province of _______________) S.S.

x-----------------------x
Affidavit of Loss Drivers License
I,
___________________,
Filipino,
of
legal
age,
(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 cant 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.

Doc. No. ____

Page No. ____
Book No. ____
Series of 20__

[13upCD]

Atty _______________________________________
Notary Public
Commission Serial No. __________________
Notary Public for _______(Province/City)_____
Until December 31, 20__
Office: ______________(address)__________
Roll No. __________
IBP Lifetime Roll No. ________; __/__/__ ; (Province)
PTR No. _________ ; __/__/__ ; _(Province)_
MCLE Compliance Cert. No. __________; __/__/__