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)
Professional Driver's License with number _____________ which is valid until
_____________;

2. Sometime on ____________, I renewed said driver's license. A temporary ID

was issued together with the Official Receipt. However, the Official Receipt
was misplaced and got lost;

3. Efforts were exerted to locate said Official Receipt, but in spite

of diligent search, it could not be found and the same is now beyond recovery;

4. Said Driver's License and Official Receipt 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 WITNESS WHEREOF, I have hereunto set my hand

this ___________________ in Manila City, Metro Manila, Philippines.

_________________

Affiant

SUBCRIBED AND SWORN TO before me this May 30, 2017 in Manila,

Philippines, affiant exhibiting to me his/her competent evidence of identity by
way of PhilHealth ID _______ issued at ______________
on __________________.

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 2013