REPUBLIC OF THE PHILIPPINES )

) S.S

AFFIDAVIT OF LOSS

I, ABS, of legal age, Filipino citizen and a resident of Brgy. 1, Sinait

Ilocos Sur, Philippines under oath and states that:

1. I am a holder of a Non-Professional Driver’s License of which I was issued

an Official Receipt (O.R.) on 27 March 2018, stamped thereon to serve as
Temporary License by the Land Transportation Office-Vigan City District
Office;

2. On 3 May 2019, while on my way to Laoag, Ilocos Norte, I noticed that

said O.R., which was last kept inside my wallet was no longer there;

3. I immediately exerted diligent search and inquiry in finding the O.R. or

Temporary Driver’s License but all my efforts proved futility. Hence, I am
now constrained to consider the same lost and beyond recovery;

4. The said O.R. was neither confiscated nor surrendered by or to the proper
authorities due to any violation of law or rule whatsoever;

5. I am therefore executing this affidavit to attest to the truth of the

foregoing, as well as to humbly request for an issuance of a new Non-
Professional Driver’s License by the Land Transportation Office;

6. Finally, this affidavit was executed for all legal intents and purposes this
may be worth.

IN WITNESS WHEREOF, I have hereunto affixed my signature this

6 day of May, 2019 at Laoag, Ilocos Norte, Philippines.
th

ABS
Affiant
ID No.________________

SUBSCRIBED AND SWORN TO before me this 6th day of May, 2019

at Laoag, Ilocos Norte, Philippines.

Doc. No.
Page No. ;
Book No. ;
Series of 2019.