REPUBLIC OF THE PHILIPPINES)

_____________________________) SS.

AFFIDAVIT OF LOSS

I, ROMMEL B. PRUDENTE, of legal age, Filipino, married, and resident of #33-T Road 2, Brgy. West
Crame, San Juan City, after being duly sworn according to law, hereby depose and state that:

1. I am the holder and owner of the Driver’s License with license no. N04-88-085017 and expiry date
of 19 January 2033 issued by the Department of Transportation under the Land Transportation
Office.
2. That on 31 December 2023, I lost the above identification card under the following circumstances:

As I was about to cash in, I had to check the account number of my ATM card
which was inside my wallet. But when I reached into my pockets to take it out,
the wallet was missing. I thought I might have left it at home, so I went back to
check, but I couldn't find it anywhere. My PSBank ATM card, SSS ID, PhilHealth
ID, TIN, Driver's License, and some cash are the only items in my wallet.

3. Despite diligent efforts exerted, I could no longer locate, find or recover the said Driver’s License,
and to the best of my knowledge, the same is truly lost.
4. The said Driver’s License has not been confiscated by any officer of the law or the issuing office
or agency due to the violation of any law, statute, order, rule or regulation.
5. In the event that the lost Driver’s License should hereafter be found or located, I undertake to
forward or surrender the same to the Land Transportation Office for appropriate disposal.
6. I am executing this Affidavit to attest to the truth of the foregoing statements and to request the
issuance of a new Driver’s License in lieu of the one which was lost.

AFFIANT FURTHER SAYETH NAUGHT.

IN WITNESS WHEREOF, I have hereunto set my hand this 02 January 2024 at Makati City.

______________________
ROMMEL B. PRUDENTE
Affiant

SUBSCRIBED AND SWORN to before me this ____________________, affiant exhibited to

me his Competent Evidence of Identity by way of __________________ issued at ______________ on
__________________.

Doc. No. ______;

Page No. ______;
Book No. ______;
Series of _______.