REPUBLIC OF THE PHILIPPINES)

QUEZON CITY
)S.S.
AFFIDAVIT OF LOSS
1. _________________________, of legal age, Filipino and a resident of
____________________________________________________,after being sworn to in
accordance with law, hereby depose and say, THAT:
2. I am registered owner /operator of the motor vehicle described as follows:
Make/Type : ___________
Motor No. : ___________
Chasis No. : ___________
Plate No. : ___________
Trade Name
Position of Affiant

C.R. No.
: __________
Current O.R. No.: __________
File No.
: __________
Classification
: __________
: ________________
: / / Chairman
/ / General Manager
/ / President
/ / Owner

2. On or about ___ A.M./P.M. of __________, my vehicle was properly parked at

_________________. When I returned to retrieve the above-described vehicle on
____________ I noticed that one/both of its plates is/are missing.
3. I lost no time in diligently trying to locate the said plate/s but all efforts exerted
proved futile and no to avail, and that the same is considered lost or stolen and beyond
recovery;
4. The said lost plate/s was/were never lent to another person or entity nor
confiscated by any other law enforcement agency;
5. I bind my self to surrender the said plates to the district office that issued the
same in the event that said plates are recovered;
6. If the DOTC thru the LTO/LTFRB, after inquiry, has found me responsible for
the unauthorized use of the herein reported lost plates, hereby signify my conformity to
be meted the administrative fines and penalties due and imposed thereon, including the
ground of the unit/s covered by the Certificate of Public Convenience issued thereof,
with waiver and distance on my part for any claim or action by reason of the aforesaid
punitive measures taken against me.
8. Purpose of this Affidavit of Loss:
/_/ For LTFRB Petition for Dropping and Substitution
/_/ For LTFRB Petition for Sale and Transfer, and/or
/_/ For securing a replacement for lost plates
8. I am executing this affidavit for the aforesaid purpose/s as well as for attesting
to the truth of the statements herein declared, subject to the rules on perjury.
AFFIANT FURTHER SAYETH NAUGHT.
_______________________
Affiant
Com. Tax Cert. No._______
Issued at ______on_______
SUBSCRIBED and SWORN to before me this ____day of ________ 2004 at
Quezon City, affiant exhibited to me his/her, community tax certificate.

Doc. No.______ Book No.___

Page No._____ Series of 2000