Republic of the Philippines)

City of Zamboanga )s.s.

X-----------------------------------X

AFFIDAVIT OF LOSS

We, ___, of legal age, married, Filipino citizen and a resident of ___,
Philippines, after having been duly sworn to in accordance with law, hereby depose
and say, that:

1. I am the registered owner of that certain motor-vehicle more particularly

identified as follows:

MAKE : HONDA
MODEL YEAR : 2015
CHASSIS NO : xxx
ENGINE NO : xxx
TYPE OF BODY : xxx
PLATE NO : xxx

2. On 08 September 2018 at around 1 o’clock in the afternoon, the said

motor-vehicle was issued a citation ticket for obstruction of sidewalk;

3. However, due to inadvertence and oversight, the said citation ticket was
misplaced and could no longer be located;

4. I exerted diligent efforts to locate and to look for the above-mentioned

citation ticket in other places but the same proved futile and to no avail;

5. For all intents and purposes, I am now declaring the above-mentioned

citation ticket is lost and beyond recovery;

6. I execute this Affidavit to attest to the truth of the foregoing facts based
on my personal knowledge, for the purpose complying with the
requirement/s of the ___ to enable me to pay the penalty in the said
citation ticket and for whatever legal purpose it may survive.

IN WITNESS WHEREOF, I have hereunto set my hand on this

__________________ at ___, Philippines.

___
Affiant
_______________________________

SUBSCRIBED AND SWORN to before me on this __________________,

at ___, Philippines. Affiant having exhibited to me his above-written Competent
Proof of Identy.

Doc. No. _____

Page No. _____
Book No. _____
Series of _____