AFFIDAVIT OF LOSS Republic of the Philippines Province Of Municipality of I, ___________________, of legal age, single/married, residing ____________, after being

sworn in accordance with law, depose and say: That I am the true owner of _______________, described as follows to wit: (Description of property) That the said automobile had been duly registered in my name in the Land Transportation Office in ___________ for the year (or years) ____________; That the certificate of registration and other pertinent papers of ownership of said automobile were among those burned and destroyed on ____________ when my house and all my personal belongings were completely destroyed by fire; That said papers are now beyond recovery. IN WITNESS WHEREOF, I have hereunto set my hand this ________ day of ________, 20__, in the Municipality of ____________, Province of __________, Philippines. ______________________ (Signature of affiant) at