Affidavit of Loss Plate
Affidavit of Loss Plate
Affidavit of Loss Plate
PROVINCE OF LAGUNA )
CITY OF CALAMBA )SS
3. I lost no time in diligently trying to locate the said plate/s but all efforts exerted proved futile and to
no avail, and that the same is considered lost stolen and beyond recovery:
4. The said lost plate/s was/were never lent to another person or entity nor confiscated by any other
law enforcement agency or has no pending or unresolved case for apprehension, alarm, suspension
or revocation;
5. I bind myself to surrender the said plates to the district office that issued the same in the event that
said plates are recovered;
6. If the DOTC thru the LTO/LTFRB, after inquiry, has found me responsible for the unauthorized use of
the herein reported loss plates, I hereby signify my conformity to be meted the administrative fines
and penalties due and imposed thereon, including the grounding of the unit/s covered by the
Certificate of Public Convenience issued therefore, with the waiver and desistance on my part for any
action by reason of the aforesaid punitive measures taken against me.
________________________________
Affiant
SUBSCRIBED AND SWORN to before me this ______ day of ________________ in the year of
Our Lord, ______, in the City of Calamba, Province of Laguna, Philippines affiant exhibited before me his
Driver’s License No. _____________________ as evidence of identity.
Doc. No.
Page No.
Book No.
Series of 2012