REPUBLIC OF THE PHILIPPINES)

Province of Agusan del Sur ) S.S.

Municipality of Prosperidad )
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AFFIDAVIT OF LOSS

I, IAN LEO U. OTAÑEZ Filipino, of legal age, and a resident of Purok 8, Brgy.
Bayugan 3, Rosario, 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’s Student Permit to drive motor vehicle .

3. Sometime in August 20, 2020, while I was at Poblacion Public Market, unconsciously I dropped
my wallet containing the copy of such LTO’s Student Permit;

4. I exercised due diligence in locating the said Student Permit and have reported its loss to the to
LTO Patin-ay, who in turn instructed me to secure this affidavit;

5. My efforts to locate my Student Permit 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 8th day of September 2020 at Patin-
ay, Prosperidad, Agusan del Sur, Philippines.
 

IAN LEO U. OTAÑEZ

Affiant
PhilHealth ID 18-025258901-3

SUBSCRIBED AND SWORN to before me, this 8th day of September 2020 at Patin-ay,
Prosperidad, Agusan del Sur, Philippines.