REPUBLIC OF THE PHILIPPINES)

PROVINCE OF BULACAN )S.S.

MUNICIPALITY OF BALAGTAS )

AFFIDAVIT OF LOSS

I, DANILO JR. SAN JUAN MATA, of legal age, Filipino, and residing at 251
Benedicto, Biñang 2nd Bocaue, Bulacan, after having been duly sworn to in accordance with law
depose and say:

1. That I am the vendee of a motorcycle more particularly described as YAMAHA

VEGA DISK 51B1, Engine No. 51B001457; Plate no. 7688-TL, that as such I am a
holder of its documents, Certificate of Registration and Official Receipt, etc;

2. That sometime on year 2021, after our house was submerged by flood brought about
by typhoon & southwest monsoon, I discovered that the envelop wherein I kept the
above said documents of my motorcycle was one of the important things that got wet,
hence, it was considered lost;

3. That I exerted effort to recover the same but proved futile and of no avail;

4. That I did not lend the said documents to anybody for him . her to use the same;

5. That I am executing this affidavit to attest to the foregoing facts; to support my report
with the LTO and other government agencies, and for all intents and legal purposes it
may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this 6th day of June, 2022,
hereat Balagtas, Bulacan.

DANILO JR. SAN JUAN MATA

Affiant
VIN: 1404-0087B-A1181DSM10000

SUBSCRIBED AND SWORN to before me this 6th day of June, 2022, hereat Balagtas,
Bulacan.

DOMICIANO A. PAGULAYAN
Notary Public
Until December 31, 2022
Doc. No. 400 PTR No. 7744661 01-03-22
Page No. 081 Balagtas, Bulacan
Book No. 033 IBP No. 022554 01-03-18
Series of 2022 Malolos City, Bulacan
Roll No. 56556 04-30-09