REPUBLIC OF THE PHILIPPINES )

MUNICIPALITY OF TIWI ) S.S

x------------------------------x

AFFIDAVIT OF LOSS
I, (AFFIANT’S FULL NAME), of legal age, Filipino and a resident of (Affiant’s complete address),
Philippines, after having been duly sworn to in accordance with law, do hereby depose and say that:

1. (State that you are the owner or holder of the document, ID, Certificate of Title for transfer, or
things that you lost, and the office, agency, institution, or person who issued the same, see
the example of a lost Driver’s License)I am the owner of a Driver’s License duly issued by the
Land Transportation Office (LTO) and registered in my name;
2. (State the place or circumstance which you normally kept the said object which was lost)I
have usually kept the same license inside my wallet and brings with me wherever I go;
3. (State how you lost the object)Few weeks ago, I went to ______ City to buy some stuffs
however upon arrival at my destination, I noticed that I lost my wallet including my Driver’s
License;
4. (If applicable, state your effort/s to find the lost object and the reason why it cannot be found)I
tried to look for the same traversing back my path wherein I could possibly dropped my wallet
and asked some people along the way but despite my efforts of finding the wallet, my search
for it and my hopes of finding the same proved futile;
5. (Your declaration that the object was lost and beyond recovery)Because of this, I declared the
same to be lost and cannot be found; and
6. (The purpose on why you executed this affidavit which commonly includes to replace the
same)I am executing this Affidavit in order to attest to the truth of the foregoing facts and for
other legal purpose(s) this may serve best.

IN WITNESS WHEREOF, I have hereunto set my hand this __(Date)________at Municipality of

Tiwi, Albay, Philippines.

(Signed)JUAN DELA CRUZ

Affiant

JURAT

The affiant, whose name and personal circumstances are stated above, personally appeared
before me this __________ in the City/Province of _______, Philippines, presented the foregoing
affidavit, signed the same in my presence and affirmed under oath to the correctness of the contents
or allegations of the same. The affiant was identified by competent evidence of identity, namely
a (must be a Government issued ID) bearing his photograph and signature.

WITNESS MY HAND AND SEAL on the place and date above-mentioned.

Doc. No. ____; NOTARY PUBLIC

Page No. ____;
Book No. ____;
Series of 2024.