REPUBLIC OF THE PHILIPPINES)

SURIGAO CITY ) S.S.

AFFIDAVIT OF LOSS

I, __________________, of legal age, married, Filipino and a resident of

_______________________, Philippines, having been duly sworn in accordance
with law, hereby depose and state THAT:

1. I was issued Official Receipt (OR) No. ____________by the LTO for the
renewal of my driver’s license

2. I have been in possession of the above-mentioned Official Receipt while

waiting for my renewed driver’s license until I could not locate the same
in my pocket last month;

3. I exerted effort to find and locate the above-mentioned OR but the same
proved futile, hence, the same is now lost and beyond recovery;

4. I am executing this Affidavit to attest the truthfulness of the foregoing

and for whatever legal purpose this may serve best.

IN WITNESS WHEREOF, I have hereunto set my hand this 8th day of

April 2019 at_______ City, Philippines.

Affiant

SUBSCRIBED AND SWORN to before me this 8th day of April

2019, at ________ City, Philippines.