REPUBLIC OF THE PHILIPPINES}

MUNICIPALITY OF PATEROS } S.S.

METRO MANILA }

AFFIDAVIT OF LOSS
(Student Permit/License)

I, RACELLI ANNE A. SANTOS, of legal age, Filipino and resident of 11 N.

Ordonez St., Ligid Tipas, Taguig City, under oath depose and say that –

1. I am a holder of a Student Permit/License issued by LTO.

2. That sometime in the last week of November 2020, I lost the aforesaid
Student Permit/License at our residence at Taguig City.

3. I exerted diligent effort to locate my Student Permit, but proved futile,

hence, I considered it already lost and beyond retrieve.

4. That the aforesaid Student Permit has not been confiscated by any lawful
authority for any violation of law and no violation or alarm.

5. That the loss of the aforesaid Student Permit was beyond my control.

6. I hereby bind myself to surrender and inform the LTO in the event that
the said Driver’s License are found or located.

7. I am executing this Affidavit of Loss to attest the truth of the foregoing

and for whatever legal purposes this may serve.

IN WITNESS WHEREOF, I affixed my signature this December 7, 2020

at Pateros, Metro Manila.

RACELLI ANNE A. SANTOS

Affiant
TIN ID No. 473-415-821-000

SUBSCRIBED AND SWORN to before me this December 7, 2020 at

Pateros, Metro Manila with Affiant affixing his signature in my presence and
within my notarial jurisdiction.

Doc. No. ____

Page No. ____
Book No. ____
Series of 2020