REPUBLIC OF THE PHILIPPINES )

)S.S.

AFFIDAVIT OF LOSS
I,
_____________________,of
legal
age,
Filipino/_______________,
single/married to _____________________ with residence and postal address at
________________________________, after having been duly sworn to in accordance
with law depose and say:
That I am the lawful holder of Non-Professional/Professional Drivers License
No.___________ issued by the Land Transportation Office with Official Receipt No.
____________ dated _________________;
That I have unfortunately lost or misplaced the aforesaid license and diligent
search proved futile;
That I am executing this affidavit to attest to the truth of the foregoing
circumstances and for the purpose of informing the authorities concerned so that a
replacement will be issued in my favor;
IN WITNESS WHEREOF, I have hereunto set my name this ___ day of
__________________________, in Quezon City, Metro Manila, Philippines.

Affiant
SUBSCRIBED AND SWORN to before me his ____ day of
______________________________ in _________________, Philippines, Affiant
exhibited to me his/her CTC No. _______________- issued at ___________________ on
_____________________.
Notary Public
Doc. No. _____;
Page No. _____;
Book No. _____;
Series of 200__.