Republic of the Philippines] Santa Cruz, Laguna ] s.s.

AFFIDAVIT OF LOSS
I, MARITES V. PANTUA, of legal age, Filipino, married and resident of Dimarses Subdivision, Batong Malake, Los Baos, Laguna, after having been sworn in accordance with law, hereby depose and state that 1. I was driving a car (Ford Fiesta) registered in the name of a friend, Maria Lourdes Amado Repaso of San Pablo City. Said vehicle is more particularly described in the attached copy of Certificate of Registration (CR) No. 28420 issued by the Land Transportation Office Muntinlupa Extension Office. Today, 14 February 2014, I went out from our house where the car was parked, I found out that the left side mirror of the said Ford Fiesta car was missing. And the same cannot be found or recovered inspite of diligent search efforts and inquiries. Hence, for all intents and purposes, the said left side mirror is now lost and beyond recovery. I executed this affidavit to attest to the truth of the foregoing declarations and for all other lawful purposes this may serve.

2.

3.

IN WITNESS WHEREFORE, I hereto affixed my signature this 14th day of February 2014 in Santa Cruz, Laguna. MARITES V. PANTUA Affiant SUBSCRIBED AND SWORN to before me this 14 February 2014 by the affiant with DTI Employment I.D. No. IV-A066 issued at DTI Victoria, Laguna.
Doc. No. _____; Page No._____; Book No._____; Series of 2014

Atty. EMMANUEL E. SANDICHO

NOTARY PUBLIC UNTIL 31 DECEMBER 2014 IBP No. 941754, 03 January 2014, Laguna PTR No. 1653109, 03 January 2014, Laguna Roll No. 42246, admitted on 9 May 1997 MCLE Compliance Period No. IV-00021894