Republic of the Philippines)

C I T Y O F D A V A O ) SS.
x- - - - - - - - - - - - - - - - - --x

AFFIDAVIT OF LOSS

I, JUSVEB G. TOMAQUIN, married, Filipino, of legal age, and a

resident of, Davao City, Philippines, after being duly sworn to in
accordance with law do hereby depose and say that:

1. I was issued an Authorization to Travel and Operate a

Tricycle for Hire with the use of Temporary Plate by the Land
Transportation Office (LTO);

2. However, sometime on December 2016, such authorization

issued by the LTO got inadvertently lost;

3. Notwithstanding diligent efforts exerted to find it, the same

was not found, recovered, or located, hence, considered lost
and destroyed for all intents and purposes;

4. I am executing this affidavit without any fraud or intent to

deceive on my part and I forever free any person from any
liability that may arise from this circumstance;

5. I am therefore executing this affidavit to attest to the truth

of all the foregoing and to apprise the LTO and other third
persons of such fact of loss and for all other legal purposes
this affidavit may serve.

IN WITNESS WHEREOF, I have hereunto affixed my signature

this ______ day of _________________ at Davao City, Philippines.

JUSVEB G. TOMAQUIN
Affiant
Drivers License No. L02-11-006762

SUBSCRIBED and SWORN to before me, in the City of

Davao, this ____ day of _______________, affiant exhibiting to me his
competent evidence of identity.

Doc No.________
Page No.________
Book No.________
Series of 2017.