REPUBLIC OF THE PHILIPPINES)

PROVINCE OF LEYTE ) S. S
CARIGARA, LEYTE )
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AFFIDAVIT OF LOSS

I, JOEL D. PARENA, of legal age, Filipino and a resident of Brgy. Abango, Barugo, Leyte,
after being sworn to in accordance with law, hereby depose and say that:

1. I am registered owner / operator of the motor vehicle described as follows:

Make/Type: Honda Plate No. : HX4269

Denomination: Tricycle Engine No. : KB5093214738

Chassis No.: KB509214734 MV File No. : 0844-00000069879

Series : TMX1559 No. of Cylinders: 1
Piston Displacement: 155 Fuel : Gas
Body Type: TC HIRE Year Model : 2011

2. On or about 9:00 o’clock in the morning of August 31, 2022, my vehicle was properly
parked outside our house. When I returned to use the above-described vehicle on
September 1, 2022, I noticed that half of the plate is missing;

3. I lost no time in diligently trying to locate the other half of the said plate, but all
efforts exerted proved futile and to no avail, and that the same is considered lost or
stolen and beyond recovery;

4. I bind myself to surrender the said plate to the district office that issued the same in
the event that said plate is recovered;

5. If the DOTC thru the LTO/LTFRB, after inquiry, has found me responsible for the
unauthorized use of the herein reported lost plates, hereby signifying 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 of any claim or action by reason
of aforesaid punitive measures taken against me;

6. 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/s.

IN WITNESS WHEREOF, I have hereunto set my hand this 1st day of September 2022
at Carigara, Leyte
 JOEL D. PARENA
Affiant
ID No.: _____________
Issued on: __________
Issued at: ___________

SUBSCRIBED AND SWORN TO before me, a notary public in and for Carigara,
Leyte this 1st day of September 2022. Affiant personally came and appeared with
______________________, 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.

Doc. No.
Book No.
Page No.
Series of 2022.