REPUBLIC OF THE PHILIPPINES)

Baguio City……………………) S.S.

AFFIDAVIT
[Re: Loss of STUDENT PERMIT]

I, RICHARD G. ANTONIO, of legal age, MARRIED , Filipino citizen, with

residence at Proper Ucab, Itogon, Benguet, after having been duly sworn to in
accordance with law, do hereby depose and state that:

I was issued a STUDENT LICENSE, by the Land Transportation Office

(LTO), Baguio City - Licensing Center.

The said driver’s license was kept inside my wallet together with equally
important documents however on August 27, 2019 the said wallet containing the
said documents was loss/missing along Pacdal Road.

Diligent efforts to locate for the loss of my STUDENT LICENSE by looking

into places where it might have been thrown away, or misplaced, and by inquiring
as to whoever might have taken it, but, unfortunately, all my efforts were in vain. I
strongly believe that my said STUDENT LICENSE was forever lost and beyond
recovery;

The same was not given to any entity for the satisfaction of any debt nor
confiscated by any law enforcement authority for violation of any law. Neither is
the same cancelled, revoked or withdrawn for violation of DOTr-CAR, LTO or
LTFRB laws, rules and regulations;

If the LTO – Baguio City Licensing Center, Baguio City, after inquiry, will
find me responsible for the unauthorized use of the herein reported lost of
my STUDENT LICENSE, I do hereby signify my conformity to meted
administrative fines and penalties due and imposed thereon, with waiver and
desistance on my part for any legal claim or action by reason of the
aforementioned punitive measures taken against me; and

I am executing this affidavit in good faith to attest to the truthfulness and

veracity of the foregoing facts and for all legal intents and purposes.

IN WITNESS WHEREOF, I have hereunto set my hand this 27Th day of

August 2019 at Baguio City, Philippines.

RICHARD G. ANTONIO
Affiant

SUBSCRIBED AND SWORN TO BEFORE ME this 27th day of August 2019 at

Baguio City, Philippines. Affiant personally appeared and is known to me to be the
person who executed this document.

RICHARD B. KILAAN
Doc No. 09 Notary Public
Page No. 02 Until December 31, 2019
Book No. XXI PTR No. 3956007; January 3, 2019
Series of 2019 IBP LIFETIME Membership No. 06440
Roll No. 44714; May 12, 1999
NA NC 59-NEW-18
MCLE Compliance No. V-0026319; 4-14-19
Unit 2 St.Joseph Bldg.,Pacdal , Baguio City 1