REPUBLIC OF THE PHILIPPINES)

BIÑAN, LAGUNA ) S.C.

AFFIDAVIT OF LOSS

I, _________________, of legal age, Filipino and a resident of

_______________________, after having been duly sworn to in accordance with law,
hereby DEPOSE and STATE:

1. That I am the lawful owner of a certain motor vehicle is more particularly

described as follows:

MAKE : ENGINE NO. :

SERIES : SERIAL/CHASIS NO.:
TYPE OF BODY : PLATE NO. :
YEAR MODEL : FILE NO. :
C.R. NO. :

2. That on 4 October 2019, the said motor vehicle was properly park in my
house at ________________________________________________ when I noticed
that the front Plate Number was missing;

3. I went back to the places I have traveled and parking areas where I used
to park the said motor vehicle in search of the said Plate Number but all
efforts to locate the same proved futile. Thus, it is presumed lost for all
intents and purposes;

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

5. That I bind myself to surrender the said plate number to the district office
that issued the same in the event that said plate is recovered;

6. That I have executed this affidavit to attest to the veracity of the foregoing
statements and to secure a replacement of the aforementioned Plate
Number.

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

_______________ 2019 at Biñan City, Laguna.

___________________
Affiant

SUBSCRIBED AND SWORN to before me this _____ day of _______________ 2019

at Biñan City, Laguna, affiant exhibiting to me her Competent Evidence of Identity with
No. _______________, issued at _________________.

Doc. No.____
Page No.___
Book No.___
Series of 2019.