REPUBLIC OF THE PHILIPPINES)

CITY OF CEBU )S.S.

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

AFFIDAVIT OF LOSS

I, ___________________, ___ years old, Filipino, single and a

resident of ______________________ City, after having been duly
sworn to in accordance with law, do hereby depose and say:
That

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 the number of
which I have no record of and I can no longer remember;

Last _________________, while attending a wedding, I found

out that my Drivers License was missing from my bag. It may
have dropped from my bag without me knowing it when I was
in the event.

Despite the diligent efforts I exerted to recover the said

Drivers License, the same could not be found anymore. Said
Drivers License issued to me is now 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 affix my

signature on this ________ day of ____________ at ________ City,
Philippines.

Affiant
 SUBSCRIBED AND SWORN to before me on this
_______day of ____________ at the City of ___________,
Philippines, affiant exhibited Community Tax Certificate No.
___________ issued at _________________________.

DOC. NO. _____; ______________

PAGE NO. _____; Notary Public
BOOK NO. _____;
SERIES OF 2016.