REPUBLIC OF THE PHILIPPINES)

QUEZON CITY

) S.S.

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

AFFIDAVIT OF LOSS

I, Robert V. Bulayungan jr , of legal age, Filipino, single and a resident of #29 V.

Francisco St.

Brgy. Krus na Ligas Diliman Quezon City , after having been duly

sworn

in

to

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 NO1-04-004949 which is valid until October 2, 2015;

2. Sometime on May 11, 2014 , 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 May 12, 2015 in
Quezon City, Metro Manila, Philippines.

____________________
Robert V. Bulayungan jr.

SUBCRIBED

AND

SWORN

TO before

me

this ___________________ in

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

of

identity

by

way

on __________________.

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 2014.

of

__________________

issued

at

______________