REPUBLIC OF THE PHILIPPINES )

______________________________ ) SS.
x- - - - - - - - - - - - - - - - - - - - - - - - - -x

AFFIDAVIT OF LOSS

I, ________________, of legal age, Filipino, and a resident of

__________________________, after having been duly sworn to in accordance
with law, depose and state that:

1. I am an employee of __________________, a duly registered independent

service provider, deployed at _________________________ as a driver;

2. As such, I was assigned a ____________ utility vehicle, with the following

details below, used as a shuttle service for the ___________ employees:

Make : Chassis No. :

Series : Plate Number :
Body Type: Year Model :

3. At around six (6) o’clock in the morning of July 01, 2022, while inspecting
the above-described vehicle prior to shuttling, I discovered that its vehicle
registration plate bearing number ______________ was detached;

4. I took diligent search and efforts to locate it, but to no avail and the same
could no longer be found;

5. I am executing this affidavit to attest to the truth of the foregoing, and to

support ____________________ application with the LTO for the
replacement and/or reissuance of the above-mentioned vehicle registration
plate, in lieu of the lost one.

IN WITNESS WHEREOF, I have hereunto set my hand this

_________________ at _______________________________.

____________________________
Affiant

SUBSCRIBED AND SWORN to before me this ________________ at

_______________________, affiant exhibited to me his Professional Driver’s
License bearing numbers ____________, valid until _______________, as
competent evidence of his identity.

Doc. No. _______;

Page No. _______;
Book No. _______;
Series of 2022.