REPUBLIC OF THE PHILIPPINES)

PROVINCE OF ) S.S.
MUN./CITY OF )

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) ProfessionalDriver'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. _____; NOTARY PUBLIC
Book No. _____;
Series of 2016.