REPUBLIC OF THE PHILIPPINES)

Province of Agusan del Sur ) S.S.

Municipality of Prosperidad )
x-----------------------x

AFFIDAVIT OF LOSS

I, ROGEN S. PUGAHAN Filipino, of legal age, and a resident of Brgy. Poblacion,

Prosperidad, Agusan del Sur, after having been sworn in accordance with law, hereby depose
and state THAT:

1. That I am the same person executing this Affidavit;

2. I am a holder of LTO Driver’s License.

3. Sometime in July 11, 2020, while I was at Poblacion Public Market, unconsciously I dropped
my wallet containing the original copy of such Drivers License ID;

4. I exercised due diligence in locating the said ID Card and have reported its loss to the Police
Station in Poblacion, Prosperidad, Agusan del Sur;

5. My efforts to locate my Driver’s License and Voters ID have failed since until now the same has
not been found, leaving me with no other recourse but to request and process for the issuance of a
replacement thereof, for which purpose this affidavit is executed; and

6. I attest to the truth of the foregoing statements.

IN WITNESS WHEREOF, I hereunto affix my signature this 30th day of July 2020 at Patin-ay,
Prosperidad, Agusan del Sur, Philippines.
 

ROGEN S. PUGAHAN
Affiant
VIN 0306-0013B-A2481RSP10000-3

SUBSCRIBED AND SWORN to before me, this 28th day of July 2020 at Patin-ay,
Prosperidad, Agusan del Sur, Philippines.