Republic of the Philippines )

Province of Isabela
)S.S.
City of Ilagan
)
x - - - - - - - - - - - - - - - - - - - - -x
AFFIDAVIT OF CHANGE OF CIVIL STATUS
I, ___________________________, of legal age, Filipino, married and a
resident of ____________________________, after having been duly sworn to in
accordance with law, hereby depose and say:
1. That I am the same person executing this affidavit;
2. That my maiden name is _______________________________;
3. That
on
______________________,
I
was
married
to
____________________________ at ___________________________
hence, any record or document showing that I am ________________
should be changed to _______________ and where my name appears as
________________________;
4. That however on _____________________, I rode my pedicab bringing
with me my wallet containing the above-mentioned license. Moments later, I
shockingly noticed that my wallet was no longer in my pocket hence I
exerted my best efforts to locate the said wallet, but all my efforts were in
vain;
5. That the said Professional Drivers License is now considered lost and
beyond recovery;
6. That I am executing this affidavit to attest to the truth of the foregoing for
whatever lawful purpose that it may serve and to notify and request the Land
Transportation Authority regarding such loss and for the issuance of a new
Professional Drivers License in place of the lost one;

IN WITNESS WHEREOF, I have hereunto set my hand this ___ day of

______________, 2015 at _______________________.

______________________
Affiant

SUBSCRIBED AND SWORN to before me this ___ day of ______________,

2015 at _______________________________.

Doc No. _____

Page No. _____

Book No . _____
Series of 2015.