REPUBLIC OF THE PHILIPPINES)

CITY OF ___________) S.S.

AFFIDAVIT OF LOSS

I, _________________________________, of legal age, __________, Filipino, and

resident of ____________________________________________________________, after
having been duly sworn on oath, hereby depose and say:

That I am a holder of a ____________________________ Driver’s License

issued by _____________________________;

That I lost the said driver’s license; that the same was stolen/missing
with/from my wallet without me noticing it;

That I took pains to locate the said driver’s license but my efforts proved
futile;

That the said driver’s license was neither confiscated by any

apprehending officer for any traffic violation or criminal offense nor
encumbered to any third persons;

That I executed this Affidavit to attest to the truthfulness of all the

foregoing and for all legal intents and purposes it may serve.

IN WITNESS WHEREOF, I have hereunto signed my name on this

__________________ at _______________ and hereby avow under penalty of law to
the whole truth of the contents of this instrument.

_________________________________
Affiant

SUBSCRIBED AND SWORN to before me on this _________________ at

______________ by Affiant with
_____________________________________________________________________________
_____________.

Doc. No.____;
Page No.____;
Book No. ;
Series of .