Affidavit of Loss

REPUBLIC OF THE PHILIPPINES)

Province/City__________________ ) SS.

AFFIDAVIT OF LOSS

I, , of legal age and residing/with address at

under oath, state:

1. THAT on while I was driving, I noticed that my Autosweep RFID card was
missing.

2. THAT my Autosweep RFID card was for with licence plate ______ /
conduction sticker _______. For Account Autosweep RFID Account Number __________________;

3. THAT I exerted diligent efforts to locate Autosweep RFID card or but to no avail and I
therefore considered the same as lost and can no longer be found;

4. THAT I am executing this Affidavit to attest to the truth of the foregoing facts and to use the
same for whatever legal purpose it may serve.

IN WITNESS HEREOF, I have hereunto affixed my signature this _____day of __________, 2020 at
________________.

Affiant

SUBSCRIBED AND SWORN to before me, this ___day of __________, 2020 in

_______________ with Affiant exhibiting their valid ID indicated under their printed name.

NOTARY PUBLIC
Doc No._______
Page No.______
Book No. ____
Series of 2020