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Republic of the Philippines)

Province of Laguna) S.S.


City/Municipality of Santa Rosa)
x-----------x
AFFIDAVIT OF LOSS
I, Ivan Psalms C. Velasco, Filipino, of legal age, married, and a resident of Santa Rosa, Laguna,
Philippines, after being duly sworn in accordance with law, depose and state:
That I am the owner of the key of a Suzuki MC Unit Ax4 (GA150DA), issued by BikeWorld on
June 23, 2016 at National Highway, Santa Rosa, Laguna.
That sometime in October 2016, my key of the said unit could not be found and that despite of
diligent search and efforts, the same could no longer be found such that I now believe that it is
now lost beyond recovery.
The said key of my Suzuki MC Unit Ax4 (GA150DA) has not been confiscated by any officer of
the law or the issuing office or agency due to the violation of any law, statute, order, rule or
regulation.
I am executing this Affidavit to attest to the truth of the foregoing statements and to request the
issuance of a duplicate key of my Suzuki MC Unit Ax4 (GA150DA) from BikeWorld in lieu of
the one which was lost.
IN WITNESS WHEREOF,I have hereunto set my hand this November 21, 2016 at Santa Rosa
City, Laguna, Philippines.

AFFIANT

SUBSCRIBED AND SWORN to before me this ____________________, affiant exhibited to me


his/her Competent Evidence of Identity by way of __________________ issued at ______________ on
__________________.
Doc. No. ______;
Page No. ______;
Book No. ______;
Series of ______.