REPUBLIC OF THE PHILIPPINES)

CITY OF MAKATI
) S.S.
x----------------------------x

AFFIDAVIT OF LOSS
I, ___________________, of legal age, Filipino, (single/married/widow)
and a resident of _______________________________, after having been
duly sworn to in accordance with law, depose and state THAT:
1. I am a duly-licensed driver in accordance with pertinent Land
Transportation laws, rules and regulations, and was issued a corresponding
(Non) Professional Driver's License with number _____________ which is
valid until _____________;
2. Sometime on ____________, said driver's license was misplaced and got
lost;
3. Efforts were exerted to locate said driver's license, but in spite of diligent
search, it could not be found and the same is now beyond recovery;
4. 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 (Non)
Professional Driver's License, in lieu of the one that was lost;
IN
WITNESS
WHEREOF,
I
have
hereunto
set
my
hand
this ___________________ in Makati City, Metro Manila, Philippines.

____________________
Affiant
SSS ID No. _____________
SUBCRIBED AND SWORN TO before me this ___________________ in
_________________, Philippines, affiant exhibiting to me his/her competent
evidence of identity by way of __________________ issued at
______________ on __________________.
Doc. No. _____;
Page No. _____;
Book No. _____;
Series of 2013.