Republic of
the Philippines )
Province of Cagayan ) S. S.
Municipality of Tuguegarao )
AFFIDAVIT OF LOSS
I, _____________________________________, of legal age, Filipino, single and a
resident of__________________________________, after having been duly sworn to an oath
and in accordance with law, hereby depose and say:
1. That I am a holder of (Student Driver’s License) with (License Number 22-030622-
6776335);
2. That sometime on (DATE OF LOST), I was surprised to discover that the said (ITEM
LOST);
3. That I tried to look for other possible places where I could find the said (ITEM LOST),
but my effort all proved futile;
4. That I honestly believe that I could no longer locate the same or is now beyond
recovery;
5. That the said (ITEM LOST) has not been confiscated by the LTO, Police or other
Traffic Enforcers for any traffic violation.
6. That I executed this Affidavit to attest the truthfulness of the foregoing and to
support my application for the issuance of a (ITEM LOST), in lieu of the one that was
lost.
Signed this ____ day of _____________, 2023 in Tuguegarao, Cagayan.
____________________________
AFFIANT
SUBSCRIBED AND SWORN to before me on the date and place above-stated by the
above-named Affiant who is personally known to me.
Doc. No. ___;
Page No. ___;
Book No. ___;
Series of 2023.
Republic of the Philippines )
Province of Cagayan )
Municipality of Tuguegarao )
AFFIDAVIT OF LOSS
I, ___________________________________f legal age, Filipino, married and a resident
of _______________________, after having been duly sworn to an oath and in accordance with
law, hereby depose and say:
7. That I am an employee of the Government Service Insurance System as an Attorney
IV;
8. That I am a holder of LTO Non-Professional Driver’s License with License No. B04-
16-005182 with Expiration on July 16, 2021;
9. That in securing my Driver’s License in 2016, I was issued an Official Receipt which I
have kept in my wallet along with my Driver’s license card;
10. That when I checked on it last week for the purpose of submitting the same as one
of the requirements for my vehicle insurance claim, I was surprised to discover that
the said Official Receipt was missing;
11. That I tried to look for other possible places where I could find the said Official
Receipt, but my effort all proved futile;
12. That I honestly believe that I could no longer locate the same or is now beyond
recovery;
13. That I executed this Affidavit to attest the truthfulness of the foregoing.
Signed this ____ day of February, 2019 in Tuguegarao, Cagayan
__________________________
Affiant
ID: GSIS ID 009470
SUBSCRIBED AND SWORN to before me on the date and place above-stated by the
above-named Affiant who is personally known to me.
Republic of the Philippines )
Province of Cagayan )
Municipality of Tuguegarao )
AFFIDAVIT OF LOSS
I, _______________________________, of legal age, Filipino, single and a resident of
_______________________________, after having been duly sworn to an oath and in
accordance with law, depose and say:
14. That I have been working with Active Cooperation for Economic Sustenance (ACES);
15. That as an employee of the ACES, I was issued an identification card;
16. That the said identification card has been in my possession and I have always kept it
inside my bag;
17. That sometime last week, I was surprised to discover that the said identification card
issued by ACES was missing;
18. That I tried to look for other possible places where I could find the said identification
card, but my effort all proved futile;
19. That I honestly believe that I could no longer locate the same or is now beyond
recovery;
20. That I executed this Affidavit to attest the truthfulness of the foregoing and
Signed this 2nd day of April, 2018 in Tuguegarao, Cagayan
________________________________
Affiant
ID:_______________________
SUBSCRIBED AND SWORN to before me on the date and place above-stated by the
above-named Affiant who is personally known to me.
SHIRLEY M. TAGAO-GUMIRAN, CPA
Cubag, Cabagan, Isabela
Doc. No. ___; Notarial Com. No.22-036 until 12-31-19
Page No. ___; Bar Roll No. 51797/May 10, 2006
Book No. ___; MCLE Exemption No. V-001218
Series of 2018. IBP Lifetime Membership No. 927478
Isabela Chapter
Republic of the Philippines )
Province of Cagayan )
Municipality of Tuguegarao )
DRIVER’S AFFIDAVIT
I, ___________________________________ age, Filipino, married and a resident of
______________________________, after having been duly sworn to an oath and in
accordance with law, depose and say:
21. That I am an employee of the GSIS and the driver of a Toyota Innova with Plate
Number
YT 7557, registered under the name of GSIS office Tuguegarao Branch;
22. That on November 3, 2016, I was directed to proceed to Malapat, Cordon, Isabela,
purposely to secure a quotation for body and paint estimate for the repair of the
aforesaid vehicle from Toyota Isabela, Inc. Office, wherein an estimate fee was
collected by the said office in the amount of Two Thousand (P2,000.00) Pesos under
Official Receipt No. 30693;
23. That such official receipt have been kept inside the vehicle but when I checked it out
for submission to the personnel in-charge in the Office I was surprised to discover
that the same is missing;
24. That I tried to look for other possible places where I could find the said document,
but my effort all proved futile;
25. That I honestly believe that I could no longer locate the same or is now beyond
recovery;
26. That I executed this Affidavit to attest the truthfulness of the foregoing.
Signed this ____ day of March, 2018 in Cabagan, ISabela.
__________________________
Affiant
SUBSCRIBED AND SWORN to before me on the date and place above-stated by the
above-named Affiant who is personally known to me.
SHIRLEY M. TAGAO-GUMIRAN, CPA
Cubag, Cabagan, Isabela
Doc. No. ___; Notarial Com. No.22-036 until 12-31-19
Page No. ___; Bar Roll No. 51797/May 10, 2006
Book No. ___; MCLE Exemption No. V-001218
Series of 2018. IBP Lifetime Membership No. 927478
Isabela Chapter
Republic of the Philippines )
Province of Isabela ) s.s.
Municipality of Cabagan )
AFFIDAVIT OF LOSS
I, MOSHE ANGELO SEBASTIAN T. SOLIVEN, of legal age, single, Filipino and a resident of
Purok 1 Cubag, Cabagan, Isabela, hereby depose and state, under oath, the following:
1. That I owned a Motorcycle covered by Certificate of Registration No. 328216431
issued on November 08, 2018, which is particularly described as follows:
MV File No.: 0201-00000766264 Plate No.: 020110
Make/Type: Yamaha Series: Mio Aerox B1W3
Engine No.: G3J1E-0252721 Chasis No.:MH3SG4650J0019253
Year model/Color: 2018/Orange
2. That as proof of ownership of the above-described motor vehicle I was issued by the
Land Transportation Office, Official Receipt (OR) and Certificate of Registration (CR);
3. That the Certificate of Registration have been kept in one of my cabinets at home.
However, when typhoon Ulyses hit the region last November 2020, a lot of
documents in our home were destroyed by flood and beyond restoration, which
forced me to dispose them;
4. That I believe among the documents disposed of were the Certificate of Registration
of my motorcycle;
5. That the aforesaid documents are now beyond recovery;
6. That I executed this Affidavit to attest the truthfulness of the foregoing and to
support my request for duplicate copies of the lost OR and CR with the Land
Transportation Office (LTO).
Signed this 24th day of October, 2022 in Cabagan, Isabela.
_______________________________
Affiant
ID No.: _________________________
SUBSCRIBED AND SWORN to before me on the date and place above-stated by the
above-named Affiant who is personally known to me.
ATTY. ROMEL L. TESTADO
Notary Public Cagayan
Doc. No. ___; Attorneys Roll No. 77987
Page No. ___; IBP Membership No. 219875
Book No. ___; MCLE Compliance No. Admitted to the bar 2022
Series of 2022. PTR No. 3108440
Valid until Dec. 31, 2023
Notarial Commission No. RTC-TUG-2022-41
Republic of the Philippines )
Province of Cagayan )
Municipality of Tuguegarao )
DRIVER’S AFFIDAVIT
I, ____________________________of legal age, Filipino, married and a resident of
__________________________________, after having been duly sworn to an oath and in
accordance with law, depose and say:
27. That I am an employee of the GSIS and the driver of a Toyota Innova with Plate
Number
YT 7557, registered under the name of GSIS office Tuguegarao Branch;
28. That on November 3, 2016, I was directed to proceed to Malapat, Cordon, Isabela,
purposely to secure a quotation for body and paint estimate for the repair of the
aforesaid vehicle from Toyota Isabela, Inc. Office, wherein an estimate fee was
collected by the said office in the amount of Two Thousand (P2,000.00) Pesos under
Official Receipt No. 30693;
29. That such official receipt have been kept inside the vehicle but when I checked it out
for submission to the personnel in-charge in the Office I was surprised to discover
that the same is missing;
30. That I tried to look for other possible places where I could find the said document,
but my effort all proved futile;
31. That I honestly believe that I could no longer locate the same or is now beyond
recovery;
32. That I executed this Affidavit to attest the truthfulness of the foregoing.
Signed this ____ day of March, 2018 in Cabagan, ISabela.
NESTOR A. BALLONGAY
Affiant
SUBSCRIBED AND SWORN to before me on the date and place above-stated by the
above-named Affiant who is personally known to me.
SHIRLEY M. TAGAO-GUMIRAN, CPA
Cubag, Cabagan, Isabela
Doc. No. ___; Notarial Com. No.22-036 until 12-31-19
Page No. ___; Bar Roll No. 51797/May 10, 2006
Book No. ___; MCLE Exemption No. V-001218
Series of 2018. IBP Lifetime Membership No. 927478
Isabela Chapter
