Republic of the Philippines)

Province of Maguindanao )S.S.

Cotabato City )
x–––––––––––––––x

AFFIDAVIT OF LOSS

I, ____________________, Filipino, of legal age, married/single, and a

resident of ____________________________, Philippines, after being duly sworn to in
accordance with law, depose and state:

1. That I am a registered owner of motor vehicle described below as to wit;

Make & Type:

Engine Number:
Chassis No:
Plate No.:

2. That sometime on __________ I was issued a Temporary Operator’s Permit/Impounding

Receipt of Motor Vehicle (TOP/IRMV) with No. _________ for parking violation.

3. That the said document while in my possession was misplaced or lost;

4. That despite diligent search and efforts to locate the said TOP/IRMV, I could not find the
same such that I now believe that they are now lost beyond recovery.

5. As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing and to
support the processing and/or settlement of my traffic apprehension case.

IN WITNESS WHEREOF, I have hereunto set my hand this __________ at ____________,

Philippines.

_____________________________
Affiant

SUBSCRIBED AND SWORN to before me this ____ day of _____________ at

_______________, Philippines, affiant exhibiting to me her CTC/ID ___________________
issued at _________ on ______________.

Notary Public

Doc. No.: ________

Page No.: ________
Book No.: ________
Series of _________