AFFIDAVIT OF LOSS

I, Majolaine T. De Castro, of legal age, Filipino, single, and resident of No. 22 Heidelberg cor. Houston St.,
BF Homes, Phase 3, Parañaque City, after being duly sworn according to law, hereby depose and state
that:

1. I am the registered owner of the sedan vehicle, Honda City, with plate no. WLI 594.
2. Early this year, I exchanged my E-PASS with the new RFID, with the RFID card, in SLEX Bicutan
office.
3. Sometime in July, while exiting the tollway to Sucat, I passed by the “RFID Only” lane, bearing in
mind that I have enough load. However, due to certain malfunctions, the RFID did not work, thus the
need to present the RFID card to notify the plaza. However, I figured that my RFID card went missing
so I had to pay for the fee PHP118.00 to be able to exit the tollgate.
4. Despite diligent efforts exerted, I could no longer locate, find or recover the said RFID card, and to
the best of my knowledge, the same is truly lost.
5. The said RFID card has not been confiscated by any officer of the law or the issuing office or agency
due to the violation of any law, statute, order, rule or regulation.
6. In the event that the lost RFID card should hereafter be found or located, I undertake to forward or
surrender the same to the SLEX Bicutan office for appropriate disposal.
7. I am executing this Affidavit to attest to the truth of the foregoing statements and to request to the
issuance of a new RFID card in lieu of the one which was lost.

IN WITNESS WHEREOF, I have hereunto set my hand this September 9, 2016 in the City of

Manila, Metro Manila, Philippines.

Marjolaine T. De Castro

Affiant

S U B C RI B ED AN D S W O R N T O b e f o r e m e t h i s___________________________i n

, Philippines, affiant exhibiting to me his/her competent evidence of identity by way

Driver’s License issued at Parañaque City on 28 March 2016.

Doc. No. ;

Page No. ;

Book No. ;

Series of 2016.