Republic of the Philippines)

La Trinidad, Benguet) s.s

x- - - - - - - - - - - - - - - - -x

AFFIDAVIT OF LOSS

I, Jacinto A. Agtulao Jr., of legal age, single, Filipino, and a resident of No 95, Happy
Homes Old Lucban, Baguio City, Philippines, after having been duly sworn to in accordance
with law, do hereby depose and state THAT:

1. I was issued a Traffic Citation Ticket (TCT) by an agent of the Land Transportation
Office (LTO) or Traffic Enforcer somewhere at Wangal, La Trinidad, Benguet
sometime on April 14, 2021 for violation of the transportation laws, traffic rules and
regulations. Consequently, the Enforcer took the Plate No. YAA 2304 of said vehicle;

2. The said TCT was kept in the back pocket of my jeans/pants after the same was
issued until it got lost sometime on April 14, 2021, the facts of its loss were as
follows;

Sometime at around 2:00 o’ clock in the afternoon of April 14, 2021, when I was
delivering water refill along La Trinidad, Benguet. I was wearing a short pant at that
time. Along with me was the said TCT, kept, at the back pocket of my short pant
together with some other personal items. When I checked on the back pocket of my
pant for the said TCT, it was then and there that I notice that the same was no longer
there or missing. It may have been dropped/fell unnoticed somewhere.

3. I therefore immediately tried to search the same but I was unable to find it. In view of
the foregoing, I strongly believed that my said TCT has been inadvertently lost
without any deliberate intent on my part whatsoever. Therefore, I considered it lost
and beyond recovery;

4. Said TCT has not been used for any illegal activities nor confiscated by any
government authorities but due to the afore cited reason;

5. That, I hereby bind myself to fully excuse the LTO/LTMPS for any damage that it
may incur for the issuance of said Car Plate;

6. Finally, I am executing this affidavit to attest to the truthfulness of the foregoing facts
and for all legal intents and purposes it may serve well.

IN WITNESS WHEREOF, I have hereunto set my hand this 15 th day of April 2021 at La
Trinidad, Benguet, Philippines.

Jacinto A. Agtulao Jr.,

Affiant
TIN ID No. 495-191-031-000

SUBSCRIBED AND SWORN to before me a Notary Public for and in La Trinidad,

Benguet, Philippines this 15th day of April 2021 by the above Affiant exhibiting to me his ID
with picture above his name and identified by to be the same person who personally signed
before me the foregoing Affidavit.

ATTY. CYRUS C. CALAYA

Doc. No. 491; Notary Public until Dec. 31, 2021
Page No. 100; PTR No. BGTCF 6233420; Jan. 4, 2021
Book No. II; IBP Lifetime No. 08051, at Pasig City
Series of 2021. Roll No. 52590, May 12, 2006; Manila
S & B Bldg., FA 224, Km. 4, La Trinidad, Benguet