REPUBLIC OF THE 

PHILIPPINES)
CITY OF DUMAGUETE) S.S.

  

AFFIDAVIT OF LOSS

I, GLORISITA A. SUNIEGA, of legal age, Filipino, widow and a resident of Bagacay,

Dumaguete City Negros Oriental, after having been sworn to in accordance with law
hereby depose and say:

1. That I am the owner of a MOTORIZED TRYCICLES OPERATION PERMIT

(MTOP) with MTOP No. 07DUM-23-1092 of a KAWASAKI MODEL BC175H,
MOTOR NO. BC175AELG3316, CHASSIS NO. BC175H-B28923, CR NO.
349332900, with PLATE NO. 072810;

2. That due to inadvertence the ORIGINAL MTOP PERMIT (or the PINK FORM)
of the said motorcycle was misplace causing for its loss;
3. That despite diligent efforts to locate the same, it could no longer be found and
that is considered lost for all intents and purposes;
4. In view thereof, I hereby declare under pain of perjury that the above-mentioned
original MTOP (PINK FORM) was not conveyed, transferred as collateral to
secure a loan from any person or lending institution;
5. That I hereby undertake that I will not hold the City Government of Dumaguete
liable, when a case may arise involving the loss of the subject original MTOP or
PINK FORM;
6. That I will not hold the City Government of Dumaguete Civilly and
administratively liable in the event any problem may arise involving the grant of a
business permit/license in favor relative to the operation of the MCH;
7. That I am executing this Affidavit to attest to the truthfulness of the foregoing
statements and for whatever legal purposes it may serve.

IN WITNESS WHEREOF, I hereby affixed my signature/s this day of

___________________ in Dumaguete City, Philippines.

GLORISITA A. SUNIEGA
Affiant

SUBCRIBED AND SWORN TO before me this ___________________ in

_________________, Philippines, affiant/s exhibiting to me her competent proof of
identity.

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 2023.