REPUBLIC OF THE PHILIPPINES )

PROVINCE OF _________________ ) S.s

CITY OF ______ )
x-------------------------------------------- x

AFFIDAVIT OF LOSS

I, ____________________, ___ years old, Filipino, and a resident of

_______________________, Philippines, after having been duly sworn to in accordance
with law, do hereby depose and state that:

1. That the Provincial Government of _____________ is the purchaser of a certain

motor vehicle more particularly described as follows:

Chassis No. -------------------------

Engine No. ------------------------
MV File No. -------------------------
Plate No. -------------------------

2. That at _____ in the morning, _________, 20___, upon going to the _______, the
original Plate No. of the above described motor vehicle issued in the name of Provincial
Government of ______________ had been lost in my custody;

3. That I have exerted all efforts to find and retrieve the said Plate Number, but to no
avail;

4. That I execute this affidavit to attest to the truth of the forgoing, and for whatever
legal purpose it may serve.

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

________________ in City of ___________________.

______________________________
Affiant

SUBSCRIBED AND SWORN to before me this __th day of

__________________ in ____________, Philippines, affiant exhibited to me his
Community Tax Certificate No. __________________.

Page No. ____

Doc No. ____
Book No. ____
Series of 20___.