Form No. 5. AFFIDAVIT OF LOSS OF DRIVER’S LICENSE.

REPUBLIC OF THE PHILIPPINES )

MUNICIPALITY OF ……………….) SS.
PROVINCE OF …………………….)

AFFIDAVIT

I, ……………….., of legal age, single/married to ……………….. and a

resident of ……………….. after having been duly sworn on oath in accordance
with law hereby voluntarily depose and say :
1 __ That I am a driver by profession, with License No. ………. Issued by
the Board of Transportation at ………………..,
2 __ That sometime between the months of ………. and ………. I was at
………. And thereat earning my livelihood as driver for Mr. ………………..,
3 __ That quite by accident, on the …. day of ………., more or less , my
wallet fell from my hip pocket while I was on my way to work; That I noted the
loss only when, upon reaching my destination, I saw that my wallet was gone,
together with my driver’s License No. ………. and a litte money.
4 __ That I took pains to look for said wallet and license but to no avail.
5 __ That I am executing this statement to attest to all the above facts , and
to request the proper authorities to grant me a new license.
IN TRUTH WHEREOF, I have hereunto signed my name below, this ….
Day of …………, 19 …. At ………………..

……………………..
Affiant