Republic of the Philippines

City of Davao ))S.S.

x-------------------------------------x

AFFIDAVIT OF LOSS

I, _________ of legal age, Filipino, and resident of _________________,

Davao City, Philippines, after having been duly sworn to in accordance with
law, do hereby depose and state that:

1. I am the authorized driver of a Motor Vehicle with Temporary Plate

No. ______________;

2. While driving the said vehicle on February 19, 2016, I was hailed by
a police officer for a traffic violation. Due to this, I was issued a
Temporary Operators Permit (TOP);

3. Sometime on May 25, 2016, I noticed that the wallet where I kept
the said permit was no longer inside my bag;

4. I diligently tried to look for the above-mentioned permit elsewhere

but all efforts to locate the same proved futile and are thus
considered lost for all legal purposes;

5. I am executing this affidavit to attest to the foregoing facts and for

any legal purpose it may serve.

IN WITNESS HEREOF, I have hereunto set my hand this 27 th day of

May 2016 in Davao City, Philippines.

______________
Affiant

SUBSCRIBED AND SWORN to before me this 27th day of May 2016 in

Davao City, Philippines, Affiant exhibiting to me his Passport ID No.
___________ as his competent evidence of identity.

Doc. No. ____;

Page No. ____;
Book No. ____;
Series of 2016.