Republic of the Philippines)

Cainta, Rizal ) SS.

AFFIDAVIT OF LOSS
I, _______________, Filipino, of legal age, single, and a resident of
_______________, under oath do hereby depose and state, that:

I was issued a TRAFFIC VIOLATION TICKET (“Ticket”) issued to me

by the _______________ for a traffic violation committed at _______________;

It so happened, however, said Ticket was lost and nowhere to be found;

I declare under penalties of perjury that this affidavit has been made in
good faith verified by me and to the best knowledge and belief is true and
correct;

Earnest efforts were exerted on my part to retrieve the same but to no

avail;

This affidavit is being executed to attest to the veracity of the foregoing

instrument in order to establish the existence of the above-mentioned Traffic
Violation Ticket and the facts of its subsequent loss for purposes not contrary
to law, morals, good custom and public policy.

IN WITNESS WHEREOF, I have hereunto set my hand this 18th day of

April 2016 at Cainta, Rizal.

_______________
Affiant

SUBSCRIBED AND SWORN TO before me on the date and at the place

above written, affiant exhibiting to me his employment I.D. with I.D. number
_______________issued by _______________bearing his photo and signature as
competent evidence of identity.

Doc. No. ;
Page No. ;
Book No. ;
Series of 2016.