Sample Affidavit of Loss (Driver's License)

Republic of the Philippines)

Quezon City ) Sc.

AFFIDAVIT OF LOSS

I, JUAN P. DELA CRUZ, Filipino, of legal age, single and with residence and postal address
at Unit 105 Silver Place Townhouse, Mango Circle, Quezon City, after having been duly sworn to in
accordance with law, hereby depose and state that:

1. Sometime in December 18, 2012, I was looking for my Driver’s License;

2. I have looked everywhere to find my Driver’s License but it was nowhere to be found;

3. Diligent efforts to locate the same was exerted but it proved futile;

4. I am executing this affidavit to attest to the truthfulness of the foregoing facts and for what legal
intents and purposes it may serve.

AFFIANT FURTHER SAYETH NAUGHT.

JUAN P. DELA CRUZ

Affiant

IN WITNESS WHEREOF, I have hereunto set my hand this 23rd day of December 2014at Quezon, City,
Philippines.

JUAN P. DELA CRUZ

Affiant

JURAT
SUBSCRIBED AND SWORN to before me this 23rd day of December 2014, affiant personally appeared
and exhibited to me his Philippine Passport No. EB-1234567 issued on July 16, 2012 in Manila,
Philippines.

NOTARY PUBLIC

Doc. No.: _____;

Page No.: _____;

Book No.: _____;

Series of 20_____.