Republic of the Philippines )

Province of La Union )S.S.

Municipality of _______ )
x----------------- --x

AFFIDAVIT OF LOSS
I, ANDREW S MEDINA, Filipino, of legal age, married, and a resident of Brgy.
Casilagan, Nagulian, La Union, Philippines, after being duly sworn to in accordance with law,
hereby depose and state:

1. That I am a holder of a Temporary Operators Permit (TOP) issued by Land

Transportation Office with number__________________;

2. That sometime on January 12, 2021 between 9:00 AM to 10:00 AM, while on my
way to office located at City of San Fernando, La Union, I discovered that the said
TOP which was placed on my back pocket was missing and nowhere to be found;

3. That despite diligent search and effort to locate the said TOP, I could not find it in
such a way that I believe that it is now lost and beyond recovery;

4. As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
statement and for all legal intents and purposes that this affidavit may serve.

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

__________at ____________, La Union, Philippines.

ANDREW S MEDINA
Affiant
ID No. __________

SUBSCRIBED AND SWORN to before me this _____day of _______ at ________, La

Union, Philippines.