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Republic of the Philippines)

Province of ____________________) S.S.


City/Municipality of _____________)
x-----------------------x

AFFIDAVIT OF LOSS

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


and a resident of _____________, Philippines, after being duly sworn
to in accordance with law, hereby depose and state:

That I am an employee of _____________ at _____________,


Philippines and at the same time a duly-licensed driver;

That on _____________ at around ________, while I was at the


_____________ at _____________, I lost my wallet which I usually
place in my back pocket;

That inside the said wallet are my Driver's License and ATM Card
issued by _____________ Bank, _____________ Branch;

That despite diligent search and efforts to locate the said wallet and
my Driver's License and my ATM Card, I could not find them such that
I now believe that they are now lost beyond recovery;

That my 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 and a new ATM Card, in lieu of the ones that were
lost.

IN WITNESS WHEREOF, I have hereunto set my hand this


_____________ at _____________, Philippines.

Affiant

(JURAT)