Republic of the Philippines) Province of _______________) S.S.

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-Affidavit of Loss Drivers License I, _____________, Filipino, of legal age, (single / married / widow), and with residence at _____________, Philippines, after being duly sworn to in accordance with law, hereby depose and state: That I am a duly-licensed driver in accordance with pertinent Land Transportation laws, rules and regulations, and was issued a corresponding Driver's License with number _____________ which is valid until _____________; That sometime last week, said Driver's License was misplaced and got lost; That despite diligent search and efforts to locate my Driver's License, I could not find the same such that I now believe that it is now lost beyond recovery; That said Driver's License has not been confiscated by the LTO, Police or other Traffic Enforcers for any traffic violation; 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 Driver's License, in lieu of the one that was lost.

IN WITNESS WHEREOF, I have hereunto set my hand this _____________ at _____________, Philippines.

_________________________________ (Signature of Affiant over Printed Name)

Jurat
REPUBLIC OF THE PHILIPPINES) PROVINCE OF _______________) CITY/MUNICIPALITY OF ______ ) S.S.

SUBSCRIBED AND SWORN to before me, in the municipality/ city of_____, this ____ day of ____, 20011, the affiant exhibiting to me his (any competent evidence of identity) issued by (issuing agency) on (date of issue) at (place of issue).

NOTARY PUBLICAppointment No. ____ Until December 31, 2010 Roll no. ____ PTR no. ____, date of issue, place of issue IBP no. _____, date of issue, place of issue Office Address: Email: Contact Number: Doc. No._____; Page No. ____; Book NO.____; Series of 2011