Republic of the Philippines 

  )
City of Cebu                        ) S.S

AFFIDAVIT OF LOSS OF DRIVER'S LICENSE

            I, (NAME OF AFFIANT), of legal age, Filipino, single/married, and a resident

of (Place of Residence), after having been duly sworn to according to law hereby depose and
state that:

1. I was a holder of a Driver’s License issued by the Land Transportation Office;

2. Sometime on January 16, 2019, I discovered the loss of said Driver’s License while
I was sifting through my personal belongings where as I can recall I kept my Driver’s
License but I could not locate the said Driver’s License;

3. I tried to look for the said Driver’s License in my wallet and in other parts of the
household but despite diligent search and efforts to locate the said Driver’s License, I could
not find it such that I now believe that I misplaced it and it is now lost beyond recovery;

4. Said lost Driver’s License was not confiscated by any officer of the law or agency
by reason of any violation of any law, ordinance, presidential decree or rules and regulation
of said agency, and neither was it given to any person;

5. As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
and for whatever legal purpose it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this (Date) at (Place),

Philippines.

                 (NAME OF AFFIANT)

SUBSCRIBED AND SWORN TO BEFORE ME this (Date) in the City of (Place),

Philippines by (Name of Affiant) who presented her ____________ ID No.
_______________  which was issued/expires on _______________ at _______________, a
government-issued identification card bearing her signature and photograph.

Doc. No. _____;

Page No. _____;                                                                    
Book No. _____;                                           
Series of _____.