REPUBLIC OF THE PHILIPPINES

CITY OF ____________________

AFFIDAVIT OF LOSS

I, _________________________________, of legal age, Filipino citizen, and a resident of

_______________________________________ after having been duly sworn to in accordance
with law, do hereby depose and say, THAT:

1. That I am the registered owner/operator of the motor vehicle, described as follows:

Make/Type: ________________ CR No.: _______________
Motor No.: ________________ Current OR no.) ________
Chassis No.: _______________ File No.: _____________
Plate No.: ____________ Classification: _________
Trade Name ___________________________________
Position of Affiant: / / Chairman / / Gen. Manager
/ / President / X/ Owner

2. On or about _______ AM/PM/ of _____________________, my vehicle was

______________________. When I returned to retrieve the above-described
vehicle that day, I noticed that one/both of its plates is/are missing.

3. I lost no time in diligently trying to locate the said plate/s but all efforts exerted proved
futile and to no avail, and that the same is considered lost or stolen and beyond recovery.

4. The said lost plate/s was/were never lent to another person or entity nor confiscated by
any other law enforcement agency.

5. I bind myself to surrender the said plates to the district office that issued the same in the
event that said plates are recovered.

6. If the DOTC thru the LTO/LTFRB, after inquiry, has found me responsible for the
unauthorized use of the herein reported lost plates, I hereby signify my conformity to be
meted the administrative fines & penalties due and imposed thereon, including the
grounding of the unit/s covered by the certificate of Public Convenience issued therefore,
with waiver and desistance on my part for any claim or action by reason of the aforesaid
punitive measures taken against me.

7. Purpose of this affidavit of loss:

/ / For LTFRB Petition for dropping and Substitution
/ / For LTFRB Petition for Sale and Transfer. And / or
/X / For securing a replacement for lost plates.

8. I am executing this affidavit for the aforesaid purpose/s as well as for attesting to the truth
of the statements herein declared, subject to the rules on perjury.

9. I am executing this affidavit purpose/s as well as for attesting to the truth of the
statements herein declared, subject to the rules on perjury.

AFFIANT FURTHER SAYETH NAUGHT.

____________________
Affiant

SUBSCRIBED AND SWORN to before me this

___________________________ at _________________________, affiant exhibited to
me his/her community tax certificate.

Doc. No.__________
Page No.__________
Book No._________
Series of 2010