Republic 

of the Philippines)
Province of  Masbate ) S.S.
City of Masbate )
x---------------------x

AFFIDAVIT OF LOSS
I, ELSIE D. TUMBAGA, Filipino, of legal age and a resident of Barangay Malinta, Masbate
City, after being duly sworn to in accordance with law, hereby depose and state:

1. That I am the registered owner of a certain motorcycle with side car which is particularly
described as follows;

Make : KAWASAKI Color : Red/Black

Type of Body : Motorcycle with MV File No. :0528-00000029357
Side Car
Year Model : 2011 C.R. NO.     : 154276220
Chassis No. : BC175A-BD5405 Plate No. : 5554IX
Engine No. : BC175AEAJ0913 Fuel : Gas

2. That on or about 4:00 in the afternoon of May 4, 2022, my vehicle was properly parked at
Barangay Sinalungan, Masbate City. When I returned to retrieve the above-described vehicle, I
noticed that its plate is missing;

3. That said lost plate was never lent to another person or entity nor confiscated by any other law
enforcement agency

4. That despite diligent efforts to recover the abovementioned plate, I could not retrieve/find the
same such that I believe that it is lost beyond recovery;

5. As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing and to support
my application for the issuance of a new plate, in lieu of the one that was lost.

IN WITNESS WHEREOF, I have hereunto set my hand this 6th day of May 2022 at Masbate
City, Philippines.

ELSIE D. TUMBAGA
Affiant

SUBSCRIBED AND SWORN to before me this 6th day of May 2022. Affiant exhibiting to me
her Postal ID No. PRN G16170295823P, as competent evidence of her identity.

Doc. No. ___

Page No. ___
Book No. ___
Series of 2022.