REPUBLIC OF THE PHILIPPINES

CITY OF URDANETA } S.S.

AFFIDAVIT OF LOSS
I, RONALDO LACA LACAMBRA, of legal age, Filipino, married, and a
resident of Sta. Clara St., VSB Subdivision, Miniem West, Sta. Barbara, Pangasinan,
after having sworn to in accordance with law, hereby, depose and state that:

1. I am the buyer of a 2007 Mitsubishi Adventure registered under

Certificate of Registration No. 263410744;

2. Pending issuance of a plate number, the Land Transportation Office (“LTO”)

issued an AUTHORZATION dated 23 January 2013 allowing the use of a temporary
plate number for the said car under plate number ZMM 527;

3. I bought the said vehicle in 15 June 2017, with no corresponding permanent

plate number;

4. Since I bought the vehicle, I asked the previous owner for the plate number,
but she could not give any, and so I exerted diligent efforts to attempt to locate and find
the same, but to no avail. Hence it is considered lost and beyond recovery;

5. Said plate number was never confiscated, revoked, cancelled, or in any way
made ineffective due to violation of any law, rule or regulation;

6. As a requirement for the issuance of another Plate Number in lieu of the lost
one, I am required to execute an affidavit of loss;

7. In compliance with the abovementioned requirement, I hereby execute this

affidavit to request the authorities concerned to issue me a new Plate Number in lieu of
the lost one; and

8. I am executing this affidavit to attest to veracity of the foregoing facts and for
whatever legal purpose it may serve.

IN WITNESS WHEREOF, I hereunto affix my signature this 16 th day of July 2020

in the City of Urdaneta.

_________________________
RONALDO LACA LACAMBRA
Affiant

SUBSCRIBED AND SWORN to before me on the date and place first above
written, affiant presenting to me, as competent proof of identity his Armed Forces of the
Philippines ID No. OTAG-EP-747732-182553 issued on 3 September 2019 in the Camp
Aguinaldo, Quezon City, Metro Manila.

Doc No.: 465

Page No.: 94
Book No.: I
Series of 2020.