Republic of the Philippines)

) S.S

AFFIDAVIT OF LOSS

I, ___________, of legal age, Filipino and a resident of Davao City, Philippines after
having been sworn to in accordance with law, hereby depose and state
that:

1. I was issued a driver’s license with license no. ___________, however the said
license was confiscated when I was apprehended by an LTO enforcer for not
wearing my seatbelt;
2. After my license was confiscated by the LTO enforcer, he then issued me a
Temporary Operator Permit (TOP);
3. That on ________ when I was arranging my personal documents I
noticed that I am unable to find my Temporary Operator Permit;
4. I exerted earnest efforts to locate the said TOP but the same could no longer
be found and should now be considered lost and beyond recovery for all intents
and purposes;
5. I am executing this affidavit to attest to the veracity of my statements and to
support the same in completing my requirements for reacquiring my Driver’s License
form the Land Transportation Office.

IN WITNESS WHEREOF, I hereunto affix my signature this _______________,

in _______________.

Affiant

SUBSCRIBED AND SWORN TO before me this __ day of ______________20 at ________ City,

Metro Manila. Affiant exhibited to me his valid identification card, and declared to me that this
instrument is her free and voluntary act and deed.

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 20