Republic of the Philippines )

CITY OF LIPA ) S.S

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

AFFIDAVIT OF LOSS OF IMPOUNDING RECEIPT

I, EDGAR ROSALES DELA PENA, Filipino Citizen, of legal age, single/married

and a resident of Base View Homes, Banay-Banay Lipa City, Batangas after
having duly sworn in accordance with law, hereby depose and say:

1. That sometime on December 2016 I was issued an ImpoUnding Receipt,

regarding a motorcycle vehicle with the following details:
a. PLATE NUMBER : DC 72875
b. CHASIS NUMBER : PAO40C000E0229630
c. MAKE : YAMAHA
d. SERIES : MIO SPORTY 0C6
e. YEAR MODEL : 2014

3. That unfortunately the Impounding Receipt was lost in my possession

sometime on December 2016 somewhere near the Barangay Post at Balagbag,
Lipa City, Batangas;

4. That despite diligent efforts to locate the official receipt all my efforts
proved futile;

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

IN WITNESS WHEREOF, I have hereunto affixed my signature this day of

_____________________ in Lipa City, Batangas.

EDGAR ROSALES DELA PENA

Driver’s License No. 001-10-003922

SUBSCRIBED AND SWORN before me this day of ___________________ at Lipa

City Philippines. Affiant exhibited to me her Government issued ID
abovementioned as competent evidence of her identity bearing her photograph
and signature in accordance with the 2004 Rules of Notarial Practice.

Doc. No._______;
Page No.______;
Book No.______;
Series of _______.