REPUBLIC OF THE PHILIPPINES )

------------------------------------------) S.S.
------------------------------------------)

AFFIDAVIT OF LOSS

I, MARX ISRAEL L. LORONO, Filipino, of legal age, and a resident of Purok

6, Gabi, Compostela, Compostela Valley, Philippines after having been
duly sworn to in accordance with the law, do hereby depose and say THAT;

1. I am a driver of a XRM 110 motor vehicle owned by the

Provincial Government of Compostela Valley bearing the
plate number SF 2896;

2. It is unfortunate that said Plate Number was accidentally

detached from said vehicle without notice;

3. Despite diligent search and efforts to locate the said license

plate, such plate number could not be found and the same is
now believed to be lost beyond recovery;

4. The lost plate was never lent to another person or entity nor
confiscated by any other law enforcement agency;

5. I bind myself to surrender the said plate to the district office

that issued the same in the event that said plate is recovered;

6. I am executing this Affidavit to attest to the truth and

veracity of the foregoing statements and to apprise the proper
authorities concerned on the matter for their information,
guidance and for whatever legal purpose/s this may serve
best.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ______ day

of ______________ at ___________________________, Philippines.

MARX ISRAEL L. LORONO

Affiant
Driver’s License No. L06-13-004130

SUBSCRIBED AND SWORN TO BEFORE ME this ________ day of _________ in

__________________, with affiant exhibited to me his above indicated competent
evidence of identity.

Doc. No. _______

Page No. _______
Book No. _______
Series of ________