REPUBLIC OF THE PHILIPPINES)

_____________________________ ) S.S.

AFFIDAVIT OF LOSS

I, (Name of Affiant)., Filipino, of legal age, residing at (Address of Affiant), after having been
sworn in accordance with law hereby depose and state:

That I am the true and lawful owner of a certain motor vehicle which
is more particularly described as follows:

MAKE : MOTOR NO. :

SERIES : SERIAL/CHASSIS NO. :
TYPE OF BODY : PLATE NO. :
YEAR MODEL : FILE NO. :

(Change the declaration below to the actual circumstances)

That sometime in June of this year, I was looking for the original
Certificate of Registration of my car but to my surprise, said Owner’s original
Copy could not found;

That I took pains to look for said Certificate of Registration, but to no

avail;

That I am executing this affidavit to attest to the truth of the foregoing

and to request from the Land Transportation Office of Angeles City, a copy of
said Certificate of Registration.

IN WITNESS WHEREOF, I have hereunto set my hand this _____ day of _______________.
20___ at _________________________.

Affiant

SIGNED IN THE PRESENCE OF:

______________________________ ____________________________

ACKNOWLEDGMENT

1
REPUBLIC OF THE PHILIPPINES)
_____________________________) SS.

BEFORE ME, a Notary Public, in and for _______________, Philippines, personally

appeared, ___________________ with ____________ issued at ___________________ on
_____________, known to me and by me known to be the same person who executed the
foregoing instrument and acknowledged to me that the same is his/her own free and voluntary
act and deed.

IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed my notarial

seal on this _______________ at ___________________, Philippines.

Doc. No. ___________;

Page No. ___________;
Book No. ___________;
Series 2019.