Republic of the Philippines )

PROVINCE OF NUEVA VIZCAYA )s.s.

MUNICIPALITY OF BAYOMBONG )

AFFIDAVIT OF LOSS
(License Plate )

I, ______________________________, of legal age, Filipino, and a resident of

______________________________, after having been duly sworn in
accordance with law, do hereby depose and state that:

1. I am the registered owner of a motor vehicle which is more particularly

describe as follows, to wit:

MAKE - - - - - - - - - ___________________
SERIES - - - - - - - - - ___________________
TYPE OF BODY - - - - - - - - - ___________________
MOTOR NO. - - - - - - - - - ___________________
CHASSIS NO. - - - - - - - - - ___________________
YEAR MODEL - - - - - - - - - ___________________
COLOR - - - - - - - - - ___________________
PLATE NO. - - - - - - - - - ___________________

2. On or about _____________________, the license plate (Front/Rear) of

the said motor vehicle was lost;

3. Despite diligent and utmost efforts in locating said license plate, the same
could not be found, thus I am now convinced that the same has already
been lost beyond recovery;

4. I am executing this Instrument to declare and attest to the veracity and

truthfulness of the foregoing and to support my application for the
issuance of new one in lieu of the one that was lost.

IN WITNESS WHEREOF, I have hereunto affixed my signature this

_______________________ hereat Bayombong, Nueva Vizcaya, Philippines.

______________________________
Affiant
ID No.

SUBSCRIBED AND SWORN TO before me this _______________________

hereat Bayombong, Nueva Vizcaya, Philippines.

Doc. No._____;
Page No._____;
Book No._____;
Series of 20___.