Republic of the Philippines )

Camiling, Tarlac
) S.S.

AFFIDAVIT OF LOSS
I, BERNARD DOMINGO y SEBASTIAN, 25 years old, Filipin-o
citizen, married and a resident of Barangay Bilad, Camiling, Tarlac,
Philippines, after having been duly sworn to in accordance with law, do
hereby depose and say THAT:
1. On December 21, 2016 at around 3:00PM, while on my home to
Barangay Bilad, Camiling, Tarlac driving the tricycle of my father, I
discovered that the TIN Plate with number 3985 of the said tricycle
was missing;
2. Immediately, I went back along the way to search for it but I found
nothing. Also, I asked the persons Ive met along the way if they
have seen the TIN Plate number of the said motorcycle but all
answered in the negative;
3. All my diligent efforts to locate the said TIN plate number proved
futile; hence, I now consider the same as lost and beyond
recovery;
4. The said plate number was never confiscated by any authority;
5. I am executing this Affidavit to attest to the truth of the foregoing
statements and for all legal intents and purposes it may serve
IN WITNESS WHEREOF, I have hereunto set my hand this 16 th day
of January, 2017 at Camiling, Tarlac, Philippines.
BERNARD S. DOMINGO
Affiant
SUBSCRIBED AND SWORN to before me on the date and place
indicated above. Affiant exhibited before me his Professional Drivers
License Card with License No. C11-12-002143, valid until 2017-13-10.

Doc. No.:_________;
Page No.:_________;
Book No.:_________;
Series of 2017.