Republic of the Philippines )

City of Dumaguete ) S.S

AFFIDAVIT OF LOSS

I, FR. ALBERT ERASMO G. BOHOL, Filipino, of legal age, single, a resident of Dumaguete
City Diocese, Dumaguete City, Negros Oriental, after having sworn to in accordance with law,
depose and say;

That I am a holder of Professional Driver’s License issued by the Land Transportation Office,
Dumaguete City;

That in view thereof, I was issued by the Land Transportation Office (LTO) an Official Receipt
(OR);

That very unfortunately, the original copy of the said Official Receipt (OR) was misplaced by
me;

That I already exerted reasonable diligence to locate the said Official Receipt (OR) but all efforts
proved futile;

That I honestly believed that the said Official Receipt (OR) is now beyond recovery;

That the said Official Receipt (OR) was not confiscated by authorities for violation of traffic
laws and I shall not hold liable employees of the LTO for any claim by third persons whatsoever as a
result of such loss;

That I am executing this affidavit to attest to the foregoing statements and to support my
application of issuance of a new Official Receipt (OR) in lieu of the one I lost and for whatever
legal purpose it may serve.

IN WITNESS WHEREOF, I have hereunto affixed my signature this __ day of 20__ in

_________ Philippines.

FR. ALBERT ERASMO G. BOHOL

Affiant

SUBSCRIBED AND SWORN TO before me this ___ day of __________ in the City of
Dumaguete, Negros Oriental, Philippines.

Doc. No.
Page No.
Book No.
Series of 2019.