REPUBLIC OF THE PHILIPPINES)

PROVINCE OF LA UNION ) Sc.

MUNICIPALITY OF TUBAO )
x-------------------------x

AFFIDAVIT OF LOSS
(MOTOR VEHICLE PLATE)
I, JAIME LOPEZ JACLA, of legal age, married, Filipino citizen, with residence and post office
address at Amallapay, Tubao, La Union, after having been duly sworn to in accordance with law, do
hereby declare and say:

1. That the registered owner of a motor vehicle bearing with PLATE Number IAA6118
issued by LTO San Fernando City, La Union and more particularly described as
follows:

MAKE TYPE : TOYOTA INNOVA WAGON

BODY TYPE : UTILITY VEHICLE
CHASSIS NO. : PA2CA8EM5HK0020292
ENGINE NO. : 1GS0263849
MODEL : 2017
PLATE NO. : IAA6118
MV FILE NO. : 0101-00000367188

2. That sometime on June 28, 2023 at around 4:00 pm, my grandson Xiao Icarus
traveled using said motor vehicle going to Pideg, Tubao, La Union and when he
arrived home, I discovered that the Plate No. IAA6118 was missing;

3. Diligent efforts were exerted to locate the same but failed, of which I presume that it
is now lost and beyond recovery;

4. The aforementioned Plate was not given to any entity for the satisfaction of any debt
nor confiscated and not apprehended by LTO and any law enforcement authority for
violation of any law;

5. If the DOTC, thru the LTO, after inquiry, has found me responsible for the
unauthorized use of the herein lost Plate, I hereby signify my conformity to be meted
with administrative fines and penalties due and imposed thereon, with waiver and
desistance on my part for any claim or action by reason of the aforementioned
punitive measures taken against me;

6. I am executing this Affidavit to attest to the truth of all the foregoing facts in support
of my request for the issuance of a replacement plate and for all legal intents and
purposes.

IN WITNESS WHEREOF, I have hereunto set my hand this 29th day of June 2023 at Tubao, La
Union.

JAIME LOPEZ JACLA

Affiant
AFPSN 659223

SUBSCRIBED AND SWORN to before me this 29th day of June 2023 at Tubao, La Union, by
the affiant appearing personally and who is known to me to be the same person who executed this
affidavit.

ATTY. JOONEE RANDYL E. RIVERA

Notary Public until December 31, 2024
Doc. No.: 131; Aspiras Highway, Francia Sur, Tubao, La Union
Page No.: 28; Roll No. 61766, TIN 929-347-628
Book No.: XLIII; PTR No. 7442264, 01-03-23, Tubao, LU
Series of 2023. IBP Life Member No. 012553; 01-02-14, SFLU
Commission No. 2022-93
MCLE No. VII-0004258, 07/21/21