Republic of the Philippines )

MUNICIPALITY OF STO. TOMAS ) S.S.

Province of Davao del Norte )
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AFFIDAVIT OF LOSS
I, JOSELITO F. GUDIO, of legal age, Filipino, married, and a resident of Purok 1A, Feeder
Road #1, Brgy. Tibal-og, Sto. Tomas, Davao del Norte, Philippines, after having been sworn to in
accordance with law, do hereby depose and state that:

1. I am the same affiant who personally and voluntarily caused the preparation and
execution of this affidavit;

2. I am the lawful owner of a certain motor vehicle, bearing the Plate No. 72714, as such, I
had been issued a Plate card by the Land Transportation Office (LTO);

3. The said Plate card of the above-described motor vehicle was missing from its holder, of
which I believed that the same was fallen unnoticed while I was within the vicinity of
Brgy. Tibal-og, Sto. Tomas, Davao del Norte, Philippines. The excerpt copy from the
original police blotter of Sto. Tomas Police Station – Sto. Tomas, Davao del Norte,
Philippines, is being attached herewith as Annex “A”;

4. Upon discovery of the lost plate, I diligently tried to locate it but all efforts exerted proved
futile and to no avail. Hence, the same is considered as permanently lost or stolen and
beyond recovery;

5. The lost plate was never lent to another person or entity nor confiscated by any other law
enforcement agency;

6. If the DOTC through the LTO/LTFRB, after inquiry, had found me responsible for the
unauthorized use of the herein reported lost plate, I hereby signify my conformity to be
meted the administrative fines and penalties due and imposed thereon, including the
grounding of unit/s covered by the Certificate of the Public Convenience issued therefore,
with waiver and desistance on my part for any claim or action by reason of the aforesaid
punitive measures taken against me;

7. Purpose of the Affidavit of Loss:

[ ] For LTFRB Petition for Dropping and Substitution

[ ] For LTFRB Petition for Sale and Transfer, and/or
[X] For securing a replacement of the lost plate number card

8. I am executing this affidavit for the aforesaid purpose as well as for attesting to the truth
of the statements herein declared, subject to the rules on perjury.

IN WITNESS WHEREOF, I have hereunto affixed my signature this May 31, 2019 at Sto.
Tomas, Davao del Norte, Philippines.

JOSELITO F. GUDIO
Affiant

SUBSCRIBED AND SWORN to before me this May 31, 2019 at Sto. Tomas, Davao del Norte,
Philippines.

Doc. No. 3;
Page No. 1;
Book No. 228;
Series of 2019.