REPUBLIC OF THE PHILIPPINES)

Province of Agusan del Sur ) S.S.

Municipality of Prosperidad )
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AFFIDAVIT OF LOSS

I, BASILIO C. SEBIAL JR., Filipino, of legal age, and a resident of Bayugan 2 San
Francisco, Agusan del Sur, after having been sworn in accordance with law, hereby depose and
state THAT:

1. That I am the same person executing this Affidavit;;

2. That I own an Honda XRM 110 motorcycle bearing KP2371, and registered in my name;

3. When I registered such motorcycle before, I was issued a Certificate Of Registration (CR) and Official
Receipt (OR);

4. Sometime in March 2019, while I was at San Francisco, Agusan del Sur buying some groceries item,
I unconsciously dropped my wallet containing the original copy of such Official Receipt (OR);

5. I exercised due diligence in locating my Official Receipt (OR) and have notified its loss to the proper
LTO Office, Patin-ay, Prosperidad, Agusan del Sur;

6. My efforts to locate my Official Receipt (OR) have failed since until now the same has not been found,
leaving me with no other recourse but to request and process for the renewal of my motorcycle
registration, for which purpose this affidavit is executed; and

7. I attest to the truth of the foregoing statements.

IN WITNESS WHEREOF, I hereunto affix my signature this 8th day of April 2019 at Patin-ay,
Prosperidad, Agusan del Sur, Philippines.

BASILIO C. SEBIAL JR.

Affiant
LTO: L01-91-013592

SUBSCRIBED AND SWORN to before me, this 8th day of April 2019 at Patin-ay, Prosperidad,
Agusan del Sur, Philippines.