Republic of the Philippines)

City of Cabadbaran....) S.S

AFFIDAVIT OF LOSS

I, ___________________________________________, of legal age, single / married and

a resident of _______________________________________________, after being duly sworn
to according to law hereby depose and say:

That I am holder of a Certificate of Registration and Official Receipt issued by the LTO:

CR NUMBER : __________________________________
OR NUMBER : __________________________________
MV FILE No. : __________________________________
MAKE : __________________________________
TYPE OF BODY : __________________________________
MOTOR No. : __________________________________
CHASSIS No. : __________________________________
COLOR : __________________________________
PLATE No. : __________________________________

That sometimes in ________________________________ the original copy of the above

said was misplaced within my personal files in my residence at
_____________________________________;

That despite diligent efforts to locate the same has been rendered futile;

That I am executing this affidavit to show proof of loss of the above-said;

In WITNESS whereof, I have hereunto set my hand this _____ day of ___________,
2017 at Cabadbaran City, Philippines.

__________________________________________
Affiant

SUBSCRIBED and SWORN to before me on the date and place first above mentioned.

Doc. No. _____________

Page No. _____________
Book No. _____________
Series of 2017