Republic of the Philippines)

_____________________ ) S.S.
x---------------- x
AFFIDAVIT OF LOSS
License Plate

I, _______________, Filipino, of legal age, married, and a resident of

___________________________, Philippines, after being duly sworn in accordance with law,
depose and state:

1. That I am the registered owner of a certain motor vehicle, more particularly described as
follows:

Make:
Motor No.:
Chassis No.:
Plate No.:

2. That on _____________, I parked near __________ until _________;

3. That on or about _________ at around ______, I discovered that my rear license

plate of the said vehicle is missing;

4. That I initially went to Police Station __, located at ______________ to inquire about my
missing plate, unfortunately the said plate is not in their custody;

5. On _____________, I went to ___________ located at ____________ to look for the

same plate but it was not also there, the officers advised me to inquire with the
________________, but the plate was also not with their safekeeping and the same thing
happened when I went to the ______________, which are located in the
______________________, respectively;

6. That despite diligent search and efforts to locate the said license plate, I could not find the
same such that I now believe that they are now lost beyond recovery.
7. As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing and to
support the application to the Land Transportation Office for the issuance of a new one in
lieu of the one that was lost.

IN WITNESS WHEREOF, I have hereunto set my hand this ___ day of _________
2019 at __________, Philippines.

____________________________
Affiant
ID: ____________

SUBSCRIBED AND SWORN to before me this _____ day of _____________ 2019 at

_____________, Philippines, affiant exhibiting to me his valid proof of identification.

Doc No.
Page No. Notary Public
Book No.
Series of 2019.