Republic of the Philippines

Province of Ilocos Sur

Municipality of Narvacan

AFFIDAVIT OF LOSS

I, GUILLERMA LUCIA C. TAN, Filipino, of legal age, residing at Brgy.

Orence, Narvacan, Ilocos Sur, after having been sworn in accordance with law
hereby depose and state:
 
That I am the true and lawful owner of a certain motorcycle which
is more particularly described as follows:
 
MAKE: SUZUKI MOTOR NO.: G427255681
SERIES: FU150DX2 SERIAL/CHASSIS NO.: BG41H506937
TYPE OF BODY: MOTORCYCLE PLATE NO.: AD81632
YEAR MODEL: 2016 FILE NO.: 0101-00000261933
   
On or about 10:00 A.M. of 18 August 2020, my Motorcycle was properly
parked at the front of Municipal Hall of Narvacan, at the back. When I returned
to retrieve the above-described vehicle on 12:00 P.M., I noticed that the plate is
missing; 

I lost no time in diligently trying to locate the said plate but all efforts
exerted proved futile and to no avail, and that the same is considered lost or
stolen and beyond recovery;

The said lost plate was never lent to another person or entity nor
confiscated by any other law enforcement agency.

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

_______________. 20___ at _________________________.
 
                  
                   
GUILLERMA LUCIA C. TAN
Affiant
        
 
          SUBSCRIBED AND SWORN to before me, this 21 st day of August 2020
in Narvacan, Ilocos Sur, with affiant exhibiting his CTC No.
Issued on ______________________ at _________________________.
 
 
                                                                                NOTARY PUBLIC

                                                                               
 
Doc.  No. :  ________;
Page  No. :  ________;
Book No. :  ________;
Series of 20_______.