Republic of the Philippines)

Province of Negros Oriental) S.S.

Municipality of Sibulan . . .)

AFFIDAVIT OF LOSS

I, JANE J. ELEMIA, of legal age, married, Filipino and a resident of Cantil-e,

Dumaguete City, Negros Oriental, after having been duly sworn to in accordance with
law, state and declare that:

1. I was previously issued a Non-Professional Driver’s License by the Land

Transportation Office (LTO) and I usually place it in my wallet;

2. That sometime on July 04, 2022, while I was checking my documents and
IDs at my house at Cantil-e, Dumaguete City, Negros Oriental, I noticed that my Non-
Professional Driver’s License was not anymore in my wallet. Perhaps, the said Non-
Professional Driver’s License fell from my wallet or was misplaced;

3. I have exerted diligent search and efforts to locate my Non-Professional

Driver’s License but the same has not been found or recovered up to the present such that
I now believe that it is now lost beyond recovery;

4. The said Non-Professional Driver’s License was not confiscated by any

law enforcement agency due to violations of traffic rules and regulations;

5. I am executing this Affidavit of Loss to establish the fact of loss of my

Non-Professional Driver’s License and to attest to the truthfulness and veracity of the
foregoing facts.

IN WITNESS WHEREOF, I have hereunto affixed my signature this

_____________ in Sibulan, Negros Oriental, Philippines.

JANE J. ELEMIA
Affiant

SUBSCRIBED AND SWORN to before me, a Notary Public, on this

_____________, for the Municipality of Sibulan and the Province of Negros Oriental,
Philippines, the above-named affiant, exhibited to me her PWD ID of City of Talisay No.
07-22-50-020-0002981, WHO SIGNED IN MY PRESENCE the foregoing document
(Affidavit of Loss), and who avows under PENALTY OF LAW to the whole truth of the
contents of the same.

Doc No. ___;

Page No. ___;
Book No. ___;
Series of 2022.

Affidavit of Loss