REPUBLIC OF THE PHILIPPINES

CITY OF ____________

) S.S.

AFFIDAVIT OF LOSS

I,
AAA,
Filipino, of legal
age,
single,
and
a
resident of ___________________, after having being duly sworn to in
accordance with law, hereby depose and state:

1. That despite diligent search and efforts to locate the said receipt
such that I now believe that it is now lost beyond recovery;

2. 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 and a new ATM Card, in
lieu of the ones that were lost.

IN WITNESS WHEREOF, I have hereunto

this_____________ at ____________________.

set

my

hand

AAA
Government Issued I.D. No. ______________________
Affiant

SUBSCRIBED AND SWORN to before me this ____day of

___________ at _______________, affiant personally appeared and
exhibited to me his government-issued I.D. bearing his photograph and
genuine signature as competent evidence of affiants identity in accordance
with the 2004 Rules on Notarial Practice.
Doc. No. _______;

Page No. _______;

Book No. _______;
Series of 2016.

Notary Public