REPUBLIC OF THE PHILIPPINES)

) S.S.

AFFIDAVIT OF LOSS

I, NAME, Filipino, of legal age, with residence address at ADDRESS after

having been duly sworn in accordance with law, depose and state that:

1. On _________________, I was issued a Philippine driver’s license

with no. ______________, issued by the Land Transportation Office (“LTO”).

2. Recently, I tried to look for my driver’s license but the same could not
be found;

3. Despite diligent efforts exerted, I could no longer locate, find or recover said
driver’s license, and to the best of my knowledge the same is truly lost and
irretrievable.

4. The said driver’s license has not been confiscated by any officer of the law
or issuing office or agency due to any violation of law, statute, order rule
or regulation

5. In the event that the lost driver’s license should hereafter be found or located,
I undertake to forward or surrender the same to the LTO for appropriate
disposal.

6. Hence, I am executing this affidavit to attest to the truth of the foregoing,

for the purpose of applying for a replacement of the said driver’s license,
and for whatever legal purpose this may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this ____day

of _____________ 2019 at Taguig City.

name
Affiant

SUBSCRIBED AND SWORN TO before me, a Notary Public in and for

Taguig City this 27th day of November 2019, the affiant exhibiting to me his
Philippine passport no. _______________ issued on ____________ at ______________,
and who was identified by me through competent evidence of identity to be the same
person who presented the foregoing instrument and signed the instrument in my
presence, and who took an oath before me as to said instrument.

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Series of 2019