REPUBLIC OF THE PHILIPPINES

( CITY OF ) S.S.

AFFIDAVIT OF LOSS
I, DELFIN PALERO CLAVILLAS of legal age, single/married, Filipino, and a resident of,
B17 L17 P2 Castillon Home Pasong Kawayan 2 General Trias Cavite, after having been
sworn to in accordance with law hereby depose and say that:

1. That I am the holder and and second buyer of Motorcycle attached herein which
are marked as ANNEX “A-series”, respectively to form part hereof..

2. That my PLATE NUMBER 2757XQ was lost On 28th of December 2022, it was
unfortunate that the said object was lost along the road going to my own
vicinity.

3. That it was late that we got informed that the said object cannot locate as of this
time.

4. That I am respectfully requesting for the replacement/(acceptance of this

affidavit) as it was mandatorily needed in my day to day living.

5. I execute this affidavit to attest to the truthfulness of the foregoing information,

and to secure the replacement/acceptance of the aforementioned object and for
whatever legal purpose it may serve.

6. FURTHER AFFIANT SAYETH NAUGHT.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of January
2023 in ____________ City, Metro Manila, Philippines

DELFIN PALERO CLAVILLAS

Affiant

SUBSCRIBED AND SWORN to before me this _____ day of January 2023 in

____________ City, Metro Manila Philippines. Affiant exhibited to me his competent
evidence of identity as __________________.

Doc No._____ NOTARY PUBLIC

Page No. ____
Book No. ____
Series of 2023