REPUBLIC OF THE PHILIPPINES)

CITY OF MANILA

) S.S.

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

AFFIDAVIT OF LOSS
I, Timothy Mark G. Maderazo, of legal age, Filipino, single, and a resident of 408 T. Anzures
St., Balic Balic Sampaloc Manila, after having been duly sworn to in accordance with law,
depose and state THAT:

1. I am a duly-licensed driver in accordance with pertinent Land Transportation laws, rules and
regulations, and was issued a corresponding Professional Driver's License with number
N0410027035 which is valid until July 19, 2017
2. Sometime on September 9, 2015, said driver's license was misplaced and got lost;
3. Efforts were exerted to locate said driver's license, but in spite of diligent search, it could not
be found and the same is now beyond recovery;
4. Said Driver's License has not been confiscated by the LTO, Police or other Traffic Enforcers for
any traffic violation;
5. As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing and
to support my application for the issuance of a new Professional Driver's License, in lieu
of the one that was lost;
IN

WITNESS

WHEREOF,

have

hereunto

set

my

hand

this ___________________ in Manila City, Metro Manila, Philippines.

____________________
Affiant
SSS ID No. 33-9351803-1
GSIS ID No. 2004462588

SUBCRIBED

AND

SWORN

TO before

me

this ___________________ in

_________________, Philippines, affiant exhibiting to me his/her competent evidence of

identity

by

way

of

on __________________.
Doc. No. _____;
Page No. _____;
Book No. _____;
Series of 2013.

__________________

issued

at

______________