Republic of the Philippines)

City of Iligan ) S.S

x---------------------------x

AFFIDAVIT OF LOSS

I, _____________, Filipino, of legal age, single, and a resident of

___________________ , after having been sworn in accordance with law
hereby depose and state:

1. That I am a duly-licensed driver in accordance with pertinent Land

Transportation laws, rules and regulations, and was issued a
corresponding Driver’s License with number ___________ which is
valid until ___________;

2. That sometime last month, said Driver’s License was misplaced and
got lost;

3. That despite diligent search and efforts to locate my Driver’s License, I

could not find the same such that I now believe that it is now lost
beyond recovery;

4. That 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 issuance of a new
Driver’s License, in lieu of the one that was lost.

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

of ____________ 2018 at ___________.

Affiant

SUBSCRIBED AND SWORN to before me this _________ day of

___________ 2018 at Iligan City, Philippines. Affiant exhibited to me his
__________________________________ issued at
_______________________.