Affidavit of Loss for License Plates

REPUBLIC OF THE PHILIPPINES )

_______________________________ )S.S.

_______________________________ )AFFIDAVIT OF LOSS

1. _________________________, of legal age, Filipino and a resident of ____________________________________________________,after being sworn to in accordance with law, hereby depose and say, THAT:

2. I am registered owner /operator of the motor vehicle described as follows:

Make/Type : ___________

C.R. No. : __________Motor No. : ___________

Current O.R. No.: __________Chasis No. : ___________

File No. : __________Plate No. : ___________

Classification : __________

Trade Name

: ________________

Position of Affiant: / / Chairman/ / General Manager

/ / President

/ / Owner

2. On or about ___ A.M./P.M. of __________, my vehicle was properly parked at ______________________. When I returned to retrieve the above-described vehicle on ______________________________ I noticed that one/both of its plates is/are missing.

3. I lost no time in diligently trying to locate the said plate/s but all efforts exerted proved futile and no to avail, and that the same is considered lost or stolen and beyond recovery;

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

5. I bind my self to surrender the said plates to the district office that issued the same in the event that said plates are recovered;

6. If the DOTC thru the LTO/LTFRB, after inquiry, has found me responsible for the unauthorized use of the herein reported lost plates, hereby signify my conformity to be meted the administrative fines and penalties due and imposed thereon, including the ground of the unit/s covered by the Certificate of Public Convenience issued thereof, with waiver and distance on my part for any claim or action by reason of the aforesaid punitive measures taken against me.

7. Purpose of this Affidavit of Loss:

/_/ For LTFRB Petition for Dropping and Substitution

/_/ For LTFRB Petition for Sale and Transfer, and/or

/_/ For securing a replacement for lost plates

8. I am executing this affidavit for the aforesaid purpose/s as well as for attesting to the truth of the statements herein declared, subject to the rules on perjury.

AFFIANT FURTHER SAYETH NAUGHT.

______________________________

Affiant

Com. Tax Cert. No.______________

Issued at _______on_____________SUBSCRIBED and SWORN to before me this ____day of ___________ 20___ at ______________________________, affiant exhibited to me his/her, community tax certificate.

ATTY _________________________________Doc. No. 123

COMMISSION NO. _____________________

Page No. 69

NOTARY PUBLIC for AGOO, LA UNIONBook No. VII

UNTIL DECEMBER 31, 2007Series of 2007

OFFICE: 9 Cases Blvd. Brgy Sta Barbara, Agoo La Union

ROLL NO. 00001

IBP NO. 1234567 ; 01/07/07 ; LA UNION

PTR NO 1234567 ; 01/07/07 ; LA UNIONMCLE COMPLIANCE No. __________; July 7, 2007