Republic of the Philippines )

Province of Cavite ) S. S.
Trece Martires City )

AFFIDAVIT OF LOSS

I, ANITA O. TAN, of legal age, married, Filipino Citizen and a

resident of 8th Floor Gedisco Tower 534Asuncion St., Binondo, Manila,
after having been duly sworn to in accordance with law deposes and
states:

1. That I am the registered owner of a certain motor vehicle

described as follows:

MAKE : ISUZU
MOTOR NO : 6HH1-204490
CHASSIS NO : FRR33P2-3000084
PLATE NO : RJY337
MV FILE NO. : 0386-00000209330

2. That unfortunately that said Plate Number was confiscated by

the Land Transportation Office (LTO) on July 16, 2016 for the
defective break light violation;

3. That when I check it out the said plate number from the LTO,
it was already revoked due to the longest of time I did not ;

4. That I bind myself to surrender the said plate to the district

office that issued the same in the event that said plate is
recovered;

5. That I have executed this affidavit to attest to the veracity of

the foregoing statements and to secure a replacement of the
aforementioned Plate Number.

IN WITNESS WHEREOF, I have hereunto affixed my signature this

__ day ________________ 2011 in Tuguegarao City, Cagayan, Philippines.

VICENTE FERMIN
Affiant

SUBSCRIBED AND SWORN to before me this __ day ______________

2011 in Tuguegarao City, Cagayan, Philippines.

Notary Public

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