(impounding Receipt) Affidavit Of Loss).docx

Republic of the Philippines ) CITY OF LIPA ) S.S x ------------------------------------------x

AFFIDAVIT OF LOSS OF IMPOUNDING RECEIPT

I, EDGAR ROSALES DELA PENA, Filipino Citizen, of legal age, single/married and a resident of Base View Homes, Banay-Banay Lipa City, Batangas after having duly sworn in accordance with law, hereby depose and say: 1. That sometime on December 2016 I was issued an ImpoUnding Receipt, regarding a motorcycle vehicle with the following details: a. PLATE NUMBER : DC 72875 b. CHASIS NUMBER : PAO40C000E0229630 c. MAKE : YAMAHA d. SERIES : MIO SPORTY 0C6 e. YEAR MODEL : 2014 3. That unfortunately the Impounding Receipt was lost in my possession sometime on December 2016 somewhere near the Barangay Post at Balagbag, Lipa City, Batangas; 4. That despite diligent efforts to locate the official receipt all my efforts proved futile; 5. That I am executing this affidavit to attest the truth of all the foregoing facts. IN WITNESS WHEREOF, I have hereunto affixed my signature this day of _____________________ in Lipa City, Batangas.

EDGAR ROSALES DELA PENA Driver’s License No. 001-10-003922 SUBSCRIBED AND SWORN before me this day of ___________________ at Lipa City Philippines. Affiant exhibited to me her Government issued ID abovementioned as competent evidence of her identity bearing her photograph and signature in accordance with the 2004 Rules of Notarial Practice. Doc. No._______; Page No.______; Book No.______; Series of _______.