Republic of the Philippines)

Malolos City, Bulcan ) S.S

AFFIDAVIT OF LOSS

I, ANGELITA B. MENDOZA, of legal age, Filipino and presently

residing at #366 I Marcelo Street, Malanday, Valenzuela City after
being duly sworn to in accordance with law depose and state, that;

1. I am an owner of a motorcycle vehicle which particularly

described as follows:

MAKE: KAWASAKI BODY NO: 81

MOTOR NO: DUMBSM52255 BODY COLOR RED
Chasis NO: MD2DDDUZZSWM79853 ZONE 1
LTO CR. NO: 12651421-6 DISTRICT 1
LTO OR NO: 3732177460 Control Plate# 10153
PLATE NO: TC-UZ9193

2. Sometime in April 2016, while driven the herein motorcycle

by my driver Fernando Nieva, he un-noticeably loss the
Control Plate# 10153 in the highway;

3. That I exerted diligent effort to locate the same but all efforts
are found futile and in vain; and

4. That executed this affidavit to attest to the truth of the

foregoing set of facts.

ANGELITA B. MENDOZA
Affiant

SUBSCRIBE AND SWORN to before me this day of ____ of May

2016. Affiant exhibited to me her VIN No.7504-0278B-
12968ABM20001-2.

Doc. No. 161:

Page No. 34:
Book No. VI:
Series 2016.