Republic of the Philippines )

Province of Ilocos Norte ) S.S

City of Laoag )
x---------------------x

AFFIDAVIT OF LOSS

1. I, Aaron Cu Dela Paz, 26 years old, male, single, businessman,

Filipino citizen and a resident of block 86 Lot 28 Laoag City, Ilocos Norte, after
having duly sworn to in accordance with the law do herby voluntarily depose and
say:

2. That at about 3:00 PM of September 2, 2021, I unnoticeably left my

car key along Bacarra Road Infront of McDonalds;

3. That I exerted diligent effort to recover the same but no avail, hence
said car key is considered lost and beyond recovery;

4. That I reported the loss of the said car key to the Laoag City Police
Station as stated under the Police Blotter Entry No. 2021-01 dated September 3,
2021, with the specification of the car below;

CAR NAME/ MODEL : Honda Altis 2014

COLOR : White Pearl Crystal
ENGINE TYPE : 2ZR-FE
Engine Displacement : 1498 cc

5. That the car key has never been confiscated nor surrendered to the
authorities;

6. That I’m executing this affidavit to establish the truthfulness of the

forgoing facts and request the concern authorities to consider the same.

IN WITNESS WHEREOF, I have hereunto set my hand this 3rd of day of

September 2021 in Laoag City.

AARON CU DELA PAZ

Affiant

SUBSCRIBE AND SWORN to before me this 3 rd day of September, 2021

at Laoag City. Affiant exhibited to me his Professional Driver’s License card duly
issued by the Land Transportation Office, Laoag Agency bearing number A0-
1810181. I hereby certify that I examined the affiant and that I am satisfied that he
voluntarily executed and understood the contents of the forgoing affidavit.

MARK JIMMY CASTRES

PUBLIC ATTORNEY II
PTR No. 21926657
Issued on: 09/03/21

Doc. No. 42433

Page No.2
Book No. 05
Series of 2021
TECH. ENGLISH 2_LEGAL FORMS: 4C_RAMOS, ROD CHRISTIAN B._AFFIDAVIT_of Loss_Car Key