REPUBLIC OF THE PHILIPPINES)

CITY OF MAKATI
) S.S.
x----------------------------x
AFFIDAVIT OF LOSS
I, ___________________, of legal age, Filipino, (single/married/widow) and a resident
of _______________________________, after having been duly sworn to in 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 _____________ which is valid until _____________;
2. Sometime on ____________, 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
this ___________________ in Makati City, Metro Manila, Philippines.

my

hand

____________________
Affiant
SSS ID No. _____________

SUBCRIBED
AND
SWORN
TO before
me
this ___________________ in
_________________, Philippines, affiant exhibiting to me his/her competent evidence of
identity
by
way
of
__________________
issued
at
______________
on __________________.
Doc. No. _____;
Page No. _____;
Book No. _____;
Series of 2013.