REPUBLIC OF THE PHILIPPINES)

TARLAC CITY. . . . . . . . . . . . . . . . )S.S.

AFFIDAVIT OF LOSS
I, ELBERT DE VILLA CATCHUELA, of legal age, Filipino, resident of
and with postal address at Sitio Planas, Tibagan, Tarlac City, after having
been duly sworn to in accordance with law do hereby depose and say:

1. I am the authorized driver of one motor vehicle which is particularly

described as follows:

MAKE AND MODEL: YAMAHA MIO

SERIAL NUMBER: MH35TL0067K857148
MOTOR NUMBER: 5TL-857647
PLATE NUMBER: 1910CH

2. That on or about 11:00 AM of August 16, 2018, the above-said vehicle

was properly parked outside our house. When I returned to retrieve the
above-described vehicle, I noticed that one of its plates is missing;

3. I lost no time in diligently trying to locate the said plate but all efforts
exerted proved futile and to no avail, and that the same is considered
lost or stolen and beyond recovery;

4. The said lost plate was never lent to another person or entity nor
confiscated by any other law enforcement agency;

5. That I am executing this affidavit to attest to the truth of the foregoing

statements and facts to inform the concerned agencies.

AFFIANT SAYETH NAUGHT.

IN WITNESS WHEREOF, I have hereunto set my hand this ___ day of

August, 2018 in the City of Tarlac, Philippines.

ELBERT DE VILLA CATCHUELA

Affiant

SUBSCRIBED AND SWORN to before me this ___ day of August,

2018 in the City of Tarlac, Philippines.

Doc. No. ______;

Page No.______;
Book No.______;
Series of 2018.