Republic of the Philippines)

S.S
AFFIDAVIT OF LOSS

I, , of legal age, Filipino and a resident 31 Gladiola Ext. Upper QM,

Baguio City, after being sworn to in accordance with law, hereby depose and
state that:

I am the owner of a Motor Vehicle bearing Plate Number XSN 299 ;

2. That on or about October 21, 2022 the back license plate of the
said vehicle was lost/missing somewhere along Tuba, Benguet;

3. I exerted diligent efforts to locate for the lost PLATE by looking

into places where the documents might have been placed but unfortunately,
all my efforts were in vain. Hence, I strongly believe that said PLATE was
forever lost and beyond recovery;

4. I am executing this affidavit of loss to attest to the truthfulness and

veracity of the foregoing facts and declarations and for the purpose
requesting the Land transportation office for the replacement of the Plate
Number for all legal intents and purposes it may serve.

IN WITNESS WHEREOF, I have hereunto signed this 24th day of

October 2022 at Baguio City, Philippines.

Affiant

SUBSCRIBED and SWORN to before me this 24th day of October

2022 at Baguio City, Philippines. Affiant personally appeared and his
known to me to be the person who executed this document.