REPUBLIC OF THE PHILIPPINES)

: s.s.
CITY OF BUTUAN..)

AFFIDAVIT OF LOSS
(Professional Drivers License)

I, _____________________, Filipino, _____ years old, married, and a

resident of ___________________________,Philippines, after having been
duly sworn to in accordance with law, depose and state:

1. That I was issued a Professional Drivers License with No.

______________ by the Land Transportation Office, Butuan City;

2. That said Drivers License has always been in my

possession until yesterday, when my wallet containing the same was
lost or misplaced by me;

3. That I have exerted diligent efforts to locate it but the

same was never found;

4. That the said license was never confiscated by lawful

authorities for any traffic violation or accident;

5. That I am executing this Affidavit of Loss to attest to the

veracity of the foregoing and to support my application for the
issuance of another Professional Drivers License in lieu of the lost one
from the Land Transportation Office, Butuan City.

IN WITNESS WHEREOF, I have hereunto affixed my signature this

______ day of _________________, 2012 at Butuan City, Philippines.

__________________________
AFFIANT

SUBSCRIBED AND SWORN TO before me this _____ day of

__________________,2012 at Butuan City, Philippines. The identity of the
affiant is established by his ____________________ with No. _____________
issued by____________________________ on __________________2012.

________________________
Public Attorney III
(Pursuant to R.A. 9406)
mvc/jdbc12