REPUBLIC OF THE PHILIPPPINES

PROVINCE OF PANGASINAN )
MUNICIPALITY OF LINGAYEN ) S.S.

AFFIDAVIT OF LOSS
RE: LOST PLATE

I, CHARITO ORDUǸA , of legal age, Filipino and a resident of Brgy Salincaoet Bugallon,
Pangasinan, after being sworn to in accordance with law, hereby depose and say;

1. That I am the son of Eduardo Orduna, the vendee of a tricycle whose original plate no.
was missing and an improvised plate no. was used as a substitute;

2. That the original owner of said tricycle was the one who lost the same and my father
who is now very old does not know the whereabouts of the original plate ;

3. That the original PLATE NO. was not given to anyone as guarantee for the payment
of certain obligation, nor mortgaged, assigned, alienated, transferred or donated the
same;

4. That I executed this Affidavit for documentation purposes and for whatever legal
purposes it may serve:

IN WITNESS WHEREOF, I have hereunto set my name this 21th day of Nov. 2017 at
Lingayen, Pangasinan.

CHARITO ORDUNA
AFFIANT

SUBSCRIBED AND SWORN to before me this 21th day of Nov. 20l7 at Lingayen,
Pangasinan.

Doc No. ______

Page No.______
Book No. _____
Series of 2017