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REPUBLIC OF THE PHILIPPINES)

CITY OF CEBU ) S.S.


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AFFIDAVIT OF LOSS

I, Julius C. Cabilao, of legal age, Filipino, (single/married/widow) and a resident of


Lower Kalunasan, Cebu 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 G0111001100 which is valid until August 29, 2016;

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 my hand this 30th day of June 2016 in
Cebu City, Philippines.

JULIUS C. CABILAO
Affiant
Community Tax Certificate__________

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 2016.