REPUBLIC OF THE PHILIPPINES )

PROVINCE OF NEGROS ORIENTAL ) S.S.

CITY OF DUMAGUETE )

AFFIDAVIT OF LOSS

I, JENEFER D. VERANO of legal age, Filipino, single, resident of and with

postal address at Quezon City,Manila, Philippines, after having been duly sworn to
hereby depose and state:

That, I am a holder of STUDENT PERMIT (OR) with License No. N16-17-

S05719 issued to me by Land Transportation Office (LTO) in Quezon City, NCR
Second District, Manila;

That, said STUDENT PERMIT (OR) was all the time carried by me,
unfortunately the same was misplaced and could no longer be retrieved;

That I have diligently tried my best to recall the circumstances of all its loss
and to recover the same but it was futile and of no avail;

That the said STUDENT PERMIT (OR), has not been confiscated nor
apprehended by any Law Enforcing Agent for Violation of the Land Transportation
and Traffic code under R. A 4136 of Memorandum Circular 899-105 nor any
Municipal or City Ordinance;

That I am executing this affidavit to support my application with its offices

for a duplicate of the said STUDENT PERMIT (OR).

IN WITNESS WHEREOF, I have here unto affixed my signature this 18th day
of December, 2017 in the City of Dumaguete, Negros Oriental Philippines.

JENEFER D. VERANO
Affiant
(License No. N16-17-S05719)

SUBCRIBED AND SWORN TO before me 18th day of December 2017 in

Dumaguete City, Philippines.