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 : ___________ C.R. No. : __________Motor No. : ___________ Current O.R. No.: __________Chasis No. : ___________ File No. : __________Plate No. : ___________ Classification : __________

Trade Name : ________________Position of Affiant : / / 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 _________________________________Doc. No. 123 COMMISSION NO. _____________________ Page No. 69 NOTARY PUBLIC 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