REPUBLIC OF THE PHILIPPINES)

CITY OF PARAÑAQUE ) S.S.

x----------------------------x

AFFIDAVIT OF LOSS

I, JANE DOE, of legal age, Filipino, Single and a resident of 0385 Quirino Ave., Don Galo,
Parañaque, 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
N34-98-096630 which is valid until March 1, 2016;
2. Sometime on August 20, 2015, 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 25th day of August, 2015 in
Parañaque City, Metro Manila, Philippines.

JANE DOE
Affiant
SSS ID No. 02-6754289-9

SUBSCRIBED and SWORN to before me this 25th day of August 2015 at Parañaque City,
the affiant having personally appeared before me and exhibited to me his/her Community Certificate.
No.009876 issued on January 2015 issued at Parañaque City.

Doc. No. 29___;

Page No. 43___; ATTY. JOSE A. DIAZ
Book No. 178__; NOTARY PUBLIC UNTIL DEC. 31, 2015
PTR # 1234567/ 2015 PARANAQUE
Series of 2015. IBP # 123456/ 2015 PARANAQUE
ROLL # 12345/ TIN # 123-456-789
MCLE COMPLIANCE III- 0011253
COMMISSION # 2014-023