Republic of the Philippines )

Province of Isabela )
Municipality of Tumauini ) S.S.

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AFFIDAVIT OF LOSS

I, RODITO M. BINALAY, of legal age, Filipino, single and a resident of Purok 5,

Barangay Balug, Tumaini, Isabela, after having been duly sworn to in accordance with law,
depose and state THAT:

1. I was issued with a TRAFFIC VIOLATION TICKET (“Ticket”) issued to me by

the police traffic enforcers for a traffic violation committed at Barangay Maligaya,
Tumauini, Isabela;

2. It so happened, however, said Ticket was lost and nowhere to be found;

3. I declare under penalties of perjury that this affidavit has been made in good faith
verified by me and to the best knowledge and belief is true and correct;

4. Earnest efforts were exerted on my part to retrieve the same but to no avail;

5. This affidavit is being executed to attest to the veracity of the foregoing instrument in
order to establish the existence of the above-mentioned Traffic Violation Ticket
and the facts of its subsequent loss for purposes not contrary to law, morals, good
custom and public policy.

IN WITNESS WHEREOF, I have hereunto set my hand this 1st day of December
2023, in the Municipality of Tumauini, Province of Isabela, Philippines.

RODITO M. BINALAY
(Signature of affiant)

SUBSCRIBED AND SWORN TO before me this 1st day of December 2023 in

Tumauini, Isabela, affiant exhibiting to me his ID No. 3137-0032A-J2194RMB10000 issued
by COMELEC at Tumauini, Isabela.
Doc. No. ____
Page No. ____
Book No. ____
Series of 2023.