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

SUBSCRIBED AND SWORN TO BEFORE ME, a notary public in and for

_________(City/Province)____________ this ____th day of ____________
20___. Affiant personally came and appeared with _____________(Competent
Evidence of Identity)______ issued by the _________(Government
Agency)______ on ___(date)__ at ________(place)_________, bearing his
photograph and signature, known to me as the same person who personally
signed the foregoing instrument before me and avowed under penalty of law to
the whole truth of the contents of said instrument.

ATTY _________________________________
COMMISSION NO. _____________________
NOTARY
PUBLIC

Doc. No. 123

Page No. 69
for
_____________________
Book No. VII
UNTIL DECEMBER 31, 200_
Series of 2007
OFFICE: _____________________
ROLL NO. 00001
IBP Lifetime Roll No. 1234567 ; 01/07/07 ; ________
PTR NO 1234567 ; 01/07/07 ; ________
MCLE COMPLIANCE No. __________; July 7, 2007