REPUBLIC OF THE PHILIPPINES )

CITY OF TAGBILARAN ) S.S.

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AFFIDAVIT OF LOSS

I, ______________________, of legal age, a resident of

___________________________, after having been duly sworn in accordance
with law hereby depose and state that:

1. I am the owner of a motor vehicle which was used by

__________________________________ of whom was subject to an
arrest on September ______, 2018, the said motor vehicle is more
particularly described as follows:

Make/Type:
Series:
Chasis No.:
Engine No.:
Plate No.:
C.R. No.:
O.R. No.:
MV File No.:

2. Sometime last September ________, 2018, at around eleven o’clock

in the evening, my husband was driving said vehicle somewhere
around the vicinity of the municipality of Panglao wherein he was
party to an arrest by the Panglao-PNP for alleged violation of Section
5 & 11 of R.A. 9165 of the Comprehensive Dangerous Drugs Act of
2012;

3. Because of such incident, the motor vehicle owned by me was

impounded by the authorities of the Panglao-PNP;

4. I hereby undertake to produce said vehicle upon the request of the

authorities if such will be needed for further proceedings on
investigation;

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 5. This affidavit is being executed to support my request for the release
of the impounded vehicle;

6. I am executing this affidavit to attest to the truthfulness of the

foregoing.

IN WITNESS WHEREOF, I have hereunto affixed my signature on this

____ day of ________________ 2018, at Tagbilaran City.

___________________________
Affiant

SUBSCRIBED and SWORN to before me this _____ day of

_______________ 2018, at Tagbilaran City. I hereby certify that I have personally
examined the above-named affiant and that I am satisfied that the foregoing
statements were given by him voluntarily and of his own free will.

Doc. No.
Page No.
Book No.
Series of:

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