REPUBLIC OF THE PHILIPPINES ) S.

S
IN MAKATI )

AFFIDAVIT OF LOSS PLATE

I, _JESSIE LAVARIAS MANZON_____________________, of legal age_41___, Filipino

Citizen, and residing at 2B AVOCADO ST.,CAA LAS PINAS CITY_after having been duly sworn
to according to law hereby depose and state:

MAKE : FORD_______________________________

ENGINE NO. : UEJAET65424___________________________

CHASSIS NO. : MPBSXXMXKSET65424_____________

PLATE NO. : AAB6701___________________________
MV FILE : 0380-156250_________________________
TYPE :HATCHBACK________________

That on ___18_____day of _AUGUST,2023____________, the Reportee personally

appeared in this office to report the above mentioned incident that on the said DTPO, based on the
affidavit of loss he presented, while traversing along Alabang Zapote Rd. upon reaching home he
discovered that the said item was already missing maybe it was accidentally detached without his
knowledge. He exerted effort to locate the same but nowhere to be found Hence, this report.

This POLICE REPORT is being issued to the above named reportee for whatever legal purposes it
may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this __________day of

______________, ________________ at _________________________________.

JESSIE LAVARIAS MANZON

AFFIANT

SUBSCRIBED AND SWORN to before me this ___________ day of ________________,

2022 in Makati.

Doc No. ;
Page No. ;
Book No. ;
Series of 2023.