Affidavit of Plate Loss

REPUBLIC OF THE PHILIPPINES) QUEZON CITY )S.S. AFFIDAVIT OF LOSS 1. _________________________, of legal age, Filipino and a resident of  _____________  ____________________ _____________ _____________ _____________ ______________ _____________ _____,after ,after being being sworn to in accordance with law, hereby depose and say, THAT: 2. I am registered registered owner owner /operator /operator of of the motor vehicle vehicle described described as as follows: follows: Mae/!ype : ___________ Motor $o. : __ _ __________ "hasis $o. : ___________ 'late $o. : ___________ !rade $ame 'osition of (ffiant

".#. $o. : __________   "%rrent &.#. $o.: __ _ _________   File $o. : __________   "lassification : __________   : ________________   : / / "hairman / / )eneral Manager   / / 'resident / / &wner  

2. &n or abo%t ___ (.M./'.M. of __________, my vehicle was properly pared at  _____________  _________________. ____. *hen I ret%rned ret%rned to retrieve the the above+described above+described vehicle on  ____________  ____________ I noticed that that one/both one/both of its its plates is/are is/are missing. missing. . I lost no time in diligently trying to locate the said plate/s b%t all efforts e-erted proved f%tile and no to avail, and that the same is considered lost or stolen and beyond recovery . !he said lost plate/s was/were never lent to another person or entity nor confiscated by any other law enforcement agency 0. I bind my self to s%rrender the said plates to the district office that iss%ed the same in the event that said plates are recovered . If the &!" thr% the 3!&/3!F#4, after in5%iry, has fo%nd me responsible for the %na%thori6ed %se of the herein reported lost plates, hereby signify my conformity to be meted the administrative fines and penalties d%e and imposed thereon, incl%ding the gro%nd of the %nit/s covered by the "ertificate of '%blic "onvenience iss%ed thereof, with waiver and distance on my part for any claim or action by reason of the aforesaid p%nitive meas%res taen against me. 7. '%rpo '%rpose se of this this (ffid (ffidavi avitt of 3oss: 3oss: /_/ For 3!F#4 'etition for ropping and 8%bstit%tion /_/ For 3!F#4 'etition for 8ale and !ransfer, and/or  /_/ For sec%ring a replacement for lost plates 7. I am e-ec%ting this affidavit for the aforesaid p%rpose/s as well as for attesting to the tr%th of the statements herein declared, s%b9ect to the r%les on per9%ry. AFFIANT FURTHER SAYETH NAUGHT.

 ____________  ___________________ ___________  ____    (ffiant "om. !a- "ert. $o._______  Iss%ed at ______on_______  SUBSCRIBED and SWORN to before me this ____day of ________ 2 at ;%e6on "ity, affiant e-hibited to me his/her, comm%nity ta- certificate.

oc. $o.______ 4oo $o.___  'age $o._____ 8eries of 2