REPUBLIC OF THE PHILIPPINES )

__________________ ___) S.S.

_____________________)

AFFIDAVIT OF LOSS

KNOWN ALL MEN BY THESE PRESENTS:

I, _____________________, Filipino, of legal age, and residing

____________________________________, after having been sworn according to law, hereby
depose and state that:

1. I am the possessor of the following document:

2. On or about ____________, I discovered the loss of the said document under the
following circumstances:

(REASON)

3. Despite diligent efforts, I could not find nor locate the same and I believe that it is truly
lost.

4. I am executing this affidavit for whatever legal purpose it may serve and to request for a
copy of the said document from ______________________________.

Affiant

SUBSCRIBED AND SWORN to before me this ___________________ at _______________,

(affiant) personally appeared before me and exhibited to me Driver’s License no. ____________
which is valid until _________________.

Doc. No.: _____;

Page No.: ______;
Book No.: ______;
Series of 2021