Affidavit of Loss

I, (Pangalan), Filipino, of legal age, presently residing at (Address ), after having been sworn to in accordance with law hereby depose and state:

1. That the Land Transportation Office issued to me a Driver’s License with No. 123456789

(Note: Ilagay ang bagay na nawala at kung kanino nanggaling, e.g., birth certificate-NSO, company ID-Company name, etc.)

2. That sometime in (buwan kung kelan nawala o ilagay ang tamang araw kung  alam mo kelan) of this year, I was looking for the (bagay na nawala) but to my surprise, said (bagay na nawala) could not be found;

3. That I took pains to look for said (bagay na nawala), but to no avail;4. That I am executing this affidavit to attest to the truth of the foregoing and to request from the Land Transportation Office of Quezon City, a new Driver’s Licence.

(Note: Ilagay ang dahilan kung bakit ginawa o purpose ng affidavit) 

IN WITNESS WHEREOF, I have hereunto set my hand this _____ day of _______________. 20___ at _________________________.

(Name Over Signature of Affiant)

REPUBLIC OF THE PHILIPPINES)
_________________________ ) S.S

SUBSCRIBED AND SWORN to before me, this ____ day of ______________, 20___ in ___________________ City, with affiant exhibiting his CTC No. _______________ , Issued on ______________________ at _________________________.