REPUBLIC OF THE PHILIPPINES)

CITY OF BACOLOD ) S.S.

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

AFFIDAVIT OF LOSS

I, ___________________, of legal age, Filipino, (single/married/widow)

and a resident of _______________________________, 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 (Non) Professional Driver's License with number
_____________ which is valid until _____________;

2. Sometime on ____________, 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
(Non) Professional Driver's License, in lieu of the one that was lost;

IN WITNESS WHEREOF, I have hereunto set my hand

this ___________________ in Makati City, Metro Manila, Philippines.

______________________

Affiant

SUBCRIBED AND SWORN TO before me this

___________________ in _________________, Philippines, affiant
exhibiting to me his/her competent evidence of identity by way of
__________________ issued at ______________ on __________________.

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 2013