REPUBLIC OF THE PHILIPPINES)

ALIAGA, NUEVA ECIJA ) S.S.

AFFIDAVIT OF LOSS

I, Frances Deanne Veruasa Romero, of legal age, Filipino, single and a resident of 426 Benita
Santos Street, Villa Benita Subdivision, Cabanatuan City, Nueva Ecija, 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 C05-10-002605 which is valid until September 28, 2018;

2. Sometime on July 2016, said driver's license was misplaced and got lost;

3. Efforts were exerted to locate said driver's license, but in spite of diligent search, it could
not be found and the same is now beyond recovery;

4. Said Driver's License 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
lieu of the one that was lost;

IN WITNESS WHEREOF, I have hereunto set my hand this ______________________ in Aliaga,

Nueva Ecija, Philippines.

Frances Deanne V. Romero

Affiant
R.C. No. ________________________
Date of Issued _______________
Place of Issued ________________________

SUBCRIBED AND SWORN TO before me this ___________________ in _________________,

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

Doc. No. ________;

Page No. ________;
Book No. ________;
Series of 2016.