Republic of the Philippines }

City of San Fernando, Pampanga } S.S.

AFFIDAVIT OF LOSS OF PLATE NUMBER

I, xxx, of legal age, married, Filipino citizen and with address at xxx, after being duly sworn in
accordance with law, depose and state:

1. I am the registered owner of the motor vehicle described as follows:

Make/Type : xxx
Denomination: xxx
Engine No. xxx
Current O.R. No.: xxx Chassis No xxx
File No.: xxx
Plate No.: xxx

2. That on or about the second quarter of 2022, I recently discovered that the plate number of said
vehicle (xxx) was irretrievably lost and can no longer be found despite diligent search and efforts
to locate the same.

3. As a result, I am signing this Affidavit of Loss to attest to the truth of the foregoing and to support
the application for the issuance of a new one in place of the one that was lost.

IN WITNESS WHEREOF, I have hereunto set my hand this xxx 2022, in the City of San
Fernando, Pampanga, Philippines.

xxx
Affiant

Republic of the Philippines }

City of San Fernando, Pampanga } S.S.
x------------------------------------------------------------x

SUBSCRIBED AND SWORN TO BEFORE ME, this ________ day of xxx, 2022 in the City of
San Fernando, Pampanga, affiant exhibited to me his government-issued ID No. _______________ with
expiry date _____________.

WITNESS MY HAND AND SEAL, on the date and place above written.

Notary public