REPUBLIC OF THE PHILIPPINES )

_______________________________ )S.S.
_______________________________ )
AFFIDAVIT OF LOSS
1. _________________________, of legal age, Filipino and a resident of
____________________________________________________,after being sworn to in
accordance with law, hereby depose and say, THAT:
2. I am registered owner /operator of the motor vehicle described as follows:
Make/Type : ___________
Motor No. : ___________
Chasis No. : ___________
Plate No. : ___________
Trade Name
Position of Affiant

C.R. No.
: __________
Current O.R. No.: __________
File No.
: __________
Classification
: __________
: ________________
: / / Chairman
/ / General Manager
/ / President
/ / Owner

2. On or about ___ A.M./P.M. of __________, my vehicle was properly parked at

______________________. When I returned to retrieve the above-described vehicle on
______________________________ I noticed that one/both of its plates is/are missing.
3. I lost no time in diligently trying to locate the said plate/s but all efforts exerted
proved futile and no to avail, and that the same is considered lost or stolen and beyond
recovery;
4. The said lost plate/s was/were never lent to another person or entity nor
confiscated by any other law enforcement agency;
5. I bind my self to surrender the said plates to the district office that issued the
same in the event that said plates are recovered;
6. If the DOTC thru the LTO/LTFRB, after inquiry, has found me responsible for
the unauthorized use of the herein reported lost plates, hereby signify my conformity to
be meted the administrative fines and penalties due and imposed thereon, including the
ground of the unit/s covered by the Certificate of Public Convenience issued thereof, with
waiver and distance on my part for any claim or action by reason of the aforesaid punitive
measures taken against me.
7. Purpose of this Affidavit of Loss:
/_/ For LTFRB Petition for Dropping and Substitution
/_/ For LTFRB Petition for Sale and Transfer, and/or
/_/ For securing a replacement for lost plates
8. I am executing this affidavit for the aforesaid purpose/s as well as for attesting
to the truth of the statements herein declared, subject to the rules on perjury.
AFFIANT FURTHER SAYETH NAUGHT.
______________________________
Affiant

Com. Tax Cert. No.______________

Issued at _______on_____________
SUBSCRIBED and SWORN to before me this ____day of ___________ 20___
at ______________________________, affiant exhibited to me his/her, community tax
certificate.

Doc. No. 123

Page No. 69
Book No. VII
Series of 2007

ATTY _________________________________
COMMISSION NO. _____________________
NOTARY PUBLIC for AGOO, LA UNION
UNTIL DECEMBER 31, 2007
OFFICE: 9 Cases Blvd. Brgy Sta Barbara, Agoo La Union
ROLL NO. 00001
IBP NO. 1234567 ; 01/07/07 ; LA UNION
PTR NO 1234567 ; 01/07/07 ; LA UNION
MCLE COMPLIANCE No. __________; July 7, 2007