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REPUBLIC OF THE PHILIPPINES)

)S.S.

AFFIDAVIT OF LOSS

I, ________________, of legal age, Filipino, and a resident of


________________, after having been sworn in accordance with law, do hereby
depose and say THAT:

1. I am the registered owner of a motor vehicle particularly described as


follows:

2. The Said Certificate of Registration was duly registered with the Land
Transportation Office;

3. Sometime in ________________________, while I am going through my


important documents at home, said Certificate of Registration was
missing;

4. I tried to locate the said Certificate of Registration but to no avail;

5. Earnest efforts were exerted to locate the whereabouts of said Certificate


of Registration but proved futile;

6. Said Certificate of Registration was not confiscated, revoked nor


surrendered to the duly constituted authorities;

7. Said Certificate of Registration is now beyond recovery;

8. I am executing this affidavit to attest to the truth of the foregoing and for
the purpose of requesting a replacement of said Certificate of
Registration.

IN WITNESS WHEREOF, I have hereunto set my hand this ________ day


of ___________________, at _______________, Philippines.

Affiant

SUBSCRIBED AND SWORN TO before me, in the ______________, this


_______ day of __________________, by affiant exhibiting to me his identification
Card with corresponding number ____________________________.

Doc. No. _______;


Page No. _______;
Book No. ______;
Series of 2018.

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