Republic of the Philippines )

Province of Cagayan ) S. S.
City of Tuguegarao )
x--------------------------------------x

AFFIDAVIT OF LOSS
I, VICENTE FERMIN, Filipino, of legal age and a resident of San Juan, Tuao,
Cagayan, after fist having been duly sworn to in accordance with law deposes and states:

1. That I was the driver of that Nissan Patrol owned by the Provincial
Government of Cagayan bearing Plate Number SCK 964;

2. It is unfortunate that said Plate Number was accidentally detached from said
Nissan Patrol without my notice;

3. That I went back to the places I have traveled 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 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 affixed my signature this __ day

________________ 2011 in Tuguegarao City, Cagayan, Philippines.

VICENTE FERMIN
Affiant

SUBSCRIBED AND SWORN to before me this __ day ______________ 2011 in

Tuguegarao City, Cagayan, Philippines.

Notary Public

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