REPUBLIC OF THE PHILIPPINES)

Province of Agusan del Sur ) S.S.

Municipality of Prosperidad )
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AFFIDAVIT OF LOSS

I, SARAH JANE B. PLAZA Filipino, of legal age, and a resident Purok 4,Barangay
3, San Francisco 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. Sometime in May 2019, while I was at San Francisco, Agusan del Sur I may have misplaced my
Driver’s License;

3. I exercised due diligence in locating my Driver’s License and have reported its loss to the proper
LTO Office, Patin-ay, Prosperidad, Agusan del Sur;

4. My efforts to locate my Driver’s License 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 of Driver’s License, for which purpose this affidavit is executed; and

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

IN WITNESS WHEREOF, I hereunto affix my signature this 14th day of June 2019 at Patin-ay,
Prosperidad, Agusan del Sur, Philippines.
 

SARAH JANE B. PLZA

Affiant

SUBSCRIBED AND SWORN to before me, this 14th day of June 2019 at Patin-ay
Prosperidad, Agusan del Sur;