REPUBLIC OF THE PHILIPPINES ) S.

S
)

AFFIDAVIT OF LOSS PLATE

I, ______________________, of legal age, Filipino Citizen, and residing at

___________________________, after having been duly sworn to according to law hereby depose
and state:

1. That I am the owner of one (1) motor vehicle and most particularly described as follows:

MAKE :
ENGINE NO. :
CHASSIS NO. :
PLATE NO. :
MV FILE :
TYPE :

2. That on ________day of _____________,2022, I park my motor vehicle in front of our house

3. That when I got home, I saw that the plate number of my motor vehicles was missing from
where it was attached;

4. I lost no time in diligently trying to locate that said plate/s but all efforts proved futile and to
no avail. Thus, the said plate/s may now be considered lost or stolen beyond recovery;

5. That the said lost plate/s was/were never lent to another person or entity nor confiscated by
any other law enforcement agency;

6. I bind myself to surrender the said plate/s to the district office that used the same in the event
that the said plate/s are recovered in due time;

7. If the DOTC thru the LTO/LTFRB, after inquiry, has found me responsible for the
unauthorized use of the herein reported lost Plate No., I hereby signify my conformity to be
meted the administrative files and penalties due and imposed thereon, including the
grounding of the units covered by Certificate of Public Convenience issued thereof, with
waiver and desistance on my part for any claim or action by. Reason of aforesaid punitive
measures taken against me.

8. Purpose of this Affidavit of Loss:

( ) renewal
( ) for securing replacement for lost Plate/s

9. That I am executing this affidavit in order to attest to the truth of the foregoing circumstances
and to report the lost of the said plate Number.

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

______________, 2022 at Makati City, Philippines.

AFFIANT

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

2024 in __________

Doc No. ;
Page No. ;
Book No. ;
Series of 2014.