Republic of the Philippines )

____________,_____________ ) S.S.

AFFIDAVIT OF LOSS

KNOW ALL MEN BY THESE PRESENTS:

I, __________________________ of legal age, Filipino, single/married, and a resident of

________________________________________________ , after having been sworn
in accordance with law, hereby deposes and states the following:

1. I am holder/owner/ or possessor of the following identification card / document:

_____________________________

2. I have recently discovered the said item/s is/are irretrievably lost and can
no longer be found despite diligent efforts to locate the same;

3. I execute this affidavit to attest to the truth of the foregoing.

Signed on the date and at the place indicated below.

Affiant
(Signature over Printed Name)
Competent Evidence of Identity
ID:
issued on:
at:

SUBSCRIBED and SWORN TO before me on the date and at the place indicated below.
The affiant exhibited to me his competent evidence of identity as indicated above.

Signed this ______________at ________________, ______________________, Philippines.

WITNESS MY HAND AND SEAL.

Notary Public

Doc. No.
Page No.
Book No. I
Series of
 “SAMPLE AND MODIFIED”

AFFIDAVIT OF LOSS

KNOW ALL MEN BY THESE PRESENTS:

I, LUISITO F. BATICANO, JR., of legal age, Filipino, single and a resident of Block 112 Lot
8, Phase 2 C II Karangalan Village, Pasig City, 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
D16-05-301715 which is valid until January 13, 2008;

4. Sometime in October 2011, said driver's license was misplaced and got lost;

5. 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;

6. Said Driver's License has not been confiscated by the LTO, Police or other Traffic Enforcers
for any traffic violation;

7. 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;

th
IN WITNESS WHEREOF, I have hereunto set my hand this 30 day of May 2014 in Pasig City,
Metro Manila, Philippines.

LUISITO F. BATICANO, JR.

Affiant

th
SUBCRIBED AND SWORN TO before me this 30 day of May 2014 in Pasig City, Philippines,
affiant exhibiting to me his competent evidence of identity by way of Voter’s I.D VIN 7403-0660B-
A1387LFB10000 issued at Pasig City.

Doc. No. _____;

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