Republic of the Philippines )

Province of Isabela )S.S.

Municipality of Cabagan )
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AFFIDAVIT OF LOSS

I, IAN KEITH M. ELGERA, of legal age, single, Filipino citizen, and a resident of
Cubag, Cabagan, Isabela after having been duly sworn to in accordance with law, do
hereby depose and state:

1. That I am a holder of Receipt and Student’s Permit issued by LTO

Makati City;

2. That on August 21, 2019 at around 12:30 in the afternoon, while I was
on my way home, I noticed that said Receipt and Student’s Permit are
missing and nowhere to be found;

3. That despite relentless efforts exerted by me, the said Receipt and
Student’s Permit cannot be found and now deemed lost;

4. That I am executing this affidavit to attest to the truth of the foregoing

facts and circumstances, issuance of new student’s permit and receipt
and for other legal purpose that this may serve.

IN WITNESS WHEROF, I have hereunto set my hand this 22 nd day of August

2019 at Cabagan, Isabela.

IAN KEITH M. ELGERA

Affiant

SUBSCRIBED AND SWORN to before me this 22nd day of August 2019 at

Cabagan, Isabela.

JHOEY C. BUENO
Public Attorney
(Pursuant to R.A. 9406)