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__

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. __________; __/__/__