REPUBLIC OF THE PHILIPPINES )

GUAGUA, PAMPANGA ) S.S.

AFFIDAVIT OF LOSS

I, __________________________________, of legal age, Filipino Citizen, with

residence at ________________________________________________ after having been duly
sworn to in accordance with law, hereby depose and state:

1.) That I am holder of LTO DRIVER’S LICENSE CARD issued by the LAND
TRANSPORTATION OFFICE;

2.) That on __________________________, I and my son went to Lubao Public

Market at Sta. Cruz Lubao, Pampanga, to purchase of our daily food consumption and when I
was about to pay the goods that we bought, I found out that my wallet was missing and I tried to
locate and find it, but to no avail;

3.) That in all likelihood the said Driver’s License Card was taken by a thief;

4.) That when I went home I tried to locate it but I failed to find the same; and

5.) That this Affidavit is executed to attest to the truth of foregoing facts and for the
purpose of informing the government authorities concerned relative the circumstances of loss of
my Driver’s License Card; and respectfully request the LAND TRANSPORATION OFFICE for
the issuance of duplicate copy or a new one.

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

___________________ at Guagua, Pampanga.

__________________________________
AFFIANT

Identification Document ___________________________________________________

SUBSCRIBED AND SWORN to before me on this ______ day of

_______________________ at Guagua, Pampanga. Affiant exhibited to me his Identification
Document stated below his name.

Doc No. ______

Page No. _____
Book No. _____
Series of 20__.