REPUBLIC OF THE PHILIPPINES)

________________________ ) SS.

AFFIDAVIT OF LOSS

I, ______________________, Filipino, of legal age, and a resident of ______________________________________,after

having been duly sworn in accordance with law, hereby depose and say:

1. That I am a holder of a drivers license ____________________ issued by the LTO _;

2. That I used to put said license card in my wallet.

3. That sometime on____________________, when I arrived home from work, I discovered that my LTO license was no longer
in my wallet where I used to place it;

4. Despite diligent search and efforts to locate said license, I could not find it.

5. That said drivers license was not confiscated by the authorities by reason of any violation of traffic rules and regulations;

6. That I am executing this affidavit to attest to the truth of the foregoing facts and to request for a replacement of said license

IN WITNESS WHEREOF , I have hereunto affixed my signature this ____day of ____________ 20___ at ____________,
Philippines. _________________________________

(Signature of Affiant over Printed Name)

SUBSCRIBED AND SWORN TO before me, a notary public in and for _____________________ this ____ day of
____________ 20___. The affiant, whom I identified through the following competent evidence of identity:_____________,
valid from______ to______ issued by_______________, personally signed theforegoing instrument before me and avowed
under penalty of law to the whole truth of the contents of said instrument.