Republic of the Philippines ) Province of Cagayan ) S. S.

City of Tuguegarao ) x--------------------------------------x

AFFIDAVIT OF LOSS
I, VICENTE FERMIN, Filipino, of legal age and a resident of San Juan, Tuao, Cagayan, after fist having been duly sworn to in accordance with law deposes and states: 1. That I was the driver of that Nissan Patrol owned by the Provincial Government of Cagayan bearing Plate Number SCK 964; 2. It is unfortunate that said Plate Number was accidentally detached from said Nissan Patrol without my notice; 3. That I went back to the places I have traveled in search of the said Plate Number but all efforts to locate the same proved futile, thus, it is presumed lost for all intents and purposes; 4. That the lost plate was never lent to another person or entity nor confiscated by any other law enforcement agency; 5. That I bind myself to surrender the said plate to the district office that issued the same in the event that said plate is recovered; 6. That I have executed this affidavit to attest to the veracity of the foregoing statements and to secure a replacement of the aforementioned Plate Number. IN WITNESS WHEREOF, I have hereunto affixed my signature this __ day ________________ 2011 in Tuguegarao City, Cagayan, Philippines. VICENTE FERMIN Affiant SUBSCRIBED AND SWORN to before me this __ day ______________ 2011 in Tuguegarao City, Cagayan, Philippines. Notary Public

Doc. No. Page No. Book No Series of