REPUBLIC OF THE PHILIPPINES )

PROVINCE OF CAGAYAN )
TUGUEGARAO CITY)

AFFIDAVIT OF LOSS OR/CR

I, ____APALONIA BUCAYU MENOR______________________________, of legal age,

Filipino,married to JAYMAR TAN MENOR and a resident of ANDAL ST. EXT., CATAGGAMAN
PARDO, TUGUEGARAO CITY, CAGAYAN, after having been duly sworn to pursuant
to law, depose andsay:

1. That I bought a certain motor vehicle to MR. RONALD BANGAYAN MARZO described below
as, to wit:
Make & Type : HONDA XRM125, 2012 MODEL
Motor Number : XRM16E181984
Chassis Number : XRM16181976
Plate Number : 6211OW

2. That , as proof of ownership of the above described vehicle he was issued by the Land
Transportation Office, Official Receipt (OR) as proof of payment and Certificate
of Registration (CR); and given to me after the deed of sale was executed.

3. That the said documents while in my possession were misplaced when we transfer our things
from our old house to our new house , the said documents could no longer be located inspite of
exerting efforts of locating them.

4. That the said documents were not in the possession of any bank institutions or lending
companies by reason of encumbrances or chattel mortgage of the subject motorvehicle;

5. That the said documents were not confiscated by any governments authorities inviolation of
R.A. 4136 and other related laws;

6. That I shall assume responsibility or liability if in any event I will use these
documents for whatever illicit transactions;

7. That I am executing this affidavit to attest to the veracity of my statements and to support the
same in its requests for duplicate copies of the lost MVRR/MVMRR/OR/CR at the Land
Transportation Office (LTO) where it has a hand over subject.

8. That I am executing this affidavit for the purpose of registering the said vehicle under my
husband’s name JAYMAR TAN MENOR
 9. That I bind myself criminally, civilly and administratively liable and will assume full responsibility
for any 3rd party claim, and hereby hold the Land Transportation Office or any of its
employees free from any liability arising from any claim for damages as a result of the approval
of the registration of the motor vehicle and or issuance of replacement certificate
or registration.

IN WITNESS HEREOF, I have hereunto set my hand this January 14, 2019 in Tuguegarao
City, Philippines.

APALONIA B. MENOR
Affiant
PRC Lic. No_____2628682________
Issued at ______Tuguegarao City_____
Issued On_______March 27, 2014__
Valid Until June 12, 2020_______

SUBSCRIBED AND SWORN, to before me this _______________ in Tuguegarao City,

Philippines, affiant exhibited to me her PRC License number of which is clearly written as
above indicated.

NOTARY PUBLIC
Doc. No: _________
Page No:_________
Book No:_________
Series of 2019