REPUBLIC OF THE PHILIPPINES
San Jose de Buenavista Antique) s.s
x………………………………………………..x
AFFIDAVIT OF LOSS
I, JESSE DALE BERTE JUANICO, of legal age, Fipino, single and a resident of
Barangay Mabasa Patnongon Antique., 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, laws and regulations, and was issued a corresponding (NON) Professional
Drivers License with number FO8-21-200713 valid until December 15, 2025.
2. Sometime on October 2, 2023, said driver’s license was misplaced and got lost;
3. Effort were exerted to locate said driver’s license, but inspite 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 ______________in
San Jose de Buenavista Antique Philippines.
JESSE DALE B. JUANICO
Affiant
SUBCRIBED AND SWORN TO before me this _____________________ in
______________________________, Philippines, affiant exhibiting to me his/her
competent evidence of identity by the way of ______________________issued
at __________________________ on ___________________.
Doc No._______________;
Page No. ______________;
Book No.______________;
Series of 2023
