REPUBLIC OF THE PHILIPPINES)

Province of _________________________) S.S.

City/Municipality of _______________)
x---------------------------x

AFFIDAVIT OF LOSS

I, ___________________________________________________________________, Filipino, of legal age,

___________________, and a resident of
, Philippines, after being duly sworn to in
accordance with law, hereby depose and state:

1 That I am an employee of _______________________________ at __________________________,

Philippines and at the same time a duly-licensed driver;

2 That on _____________ at around ________, while I was at the __________________________

at _____________, I lost my wallet which I usually place in my back pocket;

3 That inside the said wallet are my Driver's License and ATM Card issued by
_____________ Bank, _____________ Branch;

4 That despite diligent search and efforts to locate the said wallet and my Driver's
License and my ATM Card, I could not find them such that I now believe that
they are now lost beyond recovery;

5 That my Driver's License has not been confiscated by the LTO, Police or other
Traffic Enforcers for any traffic violation;

6 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 Driver's
License and a new ATM Card, in lieu of the ones that were lost.

IN WITNESS WHEREOF, I have hereunto set my hand this _____________ at

_____________, Philippines.

Affiant

SUBSCRIBED AND SWORN to before me, this , by the

Affiant whom I have identified through competent evidence of identity and who exhibited
his issued at on ____
_________.

Doc. No. ______;

Page No. ______;
Book No.______;
Series of 20____.