REPUBLIC OF THE PHILIPPINES)

CITY OF _____ ) S.S.

x----------------------------x
AFFIDAVIT OF LOSS

I, ______, of legal age, Filipino, married and a resident of ______, after having been duly
sworn to in accordance with law, hereby 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 October 27, 2018;

2. Sometime on June 30, 2017, I attended an event in Mandaluyong City and misplaced and
lost some of the contents of my wallet including the Official Receipt of my Drivers License;

3. Efforts were exerted to locate said Official Receipt, but in spite of diligent search, it could
not be found and I believe the same is now beyond recovery;

4. Said Official Receipt 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 Official Receipt of my Non-
Professional Driver's License, in lieu of the one that was lost, for renewal purposes;

6. Lastly, attached herewith as Annex A is my original Drivers License and photocopy

thereof for your reference;

IN WITNESS WHEREOF, I have hereunto set my hand this July 3, 2017 in Pasic City,
Metro Manila, Philippines.
____________________________
Affiant

Valid ID No. ____________________________

SUBCRIBED AND SWORN TO before me this July 3, 2017 in Pasig City, Philippines,
affiant exhibiting to me his competent evidence of identity by way of
____________________________ issued at ________________
on ____________________.

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 2017.