Republic of the Philippines

Province of ______________
_____________
x----------------------------x

Affidavit of Loss
[temporary operator’s permit (TOP)]

I, _____________________, Filipino, of legal age, married, and a bona fide

resident of ___________________, after having been duly sworn to in
accordance with law, depose that:

1. My uncle, ____________________ was issued a temporary operator’s permit

(TOP).

2. For safekeeping purposes, he gave to me said TOP, because sometimes, the

documents he has, are often mixed with old receipts and bills.

3. Unfortunately, I lost the TOP. I exerted all efforts to look for it, or retrieve it, but
my efforts proved futile. Hence, this Affidavit.

4. I execute this affidavit, under the pains and penalties of perjury, as to the
truthfulness thereof.

IN WITNESS WHEREOF, I set my hand this ____day of August, 20___ in

____________________

_______________________
Affiant

SUBSCRIBED AND SWORN TO BEFORE ME on the same date and at the

same place above-written.
The affiant is identified through ID __________________.

Doc. No. ______;

Page No. ______;
Book No. ______;
Series of 20___.