AFFIDAVIT OF LOSS

TO WHOM IT MAY CONCERN:

That I, ALONA D. CADAG, a resident of Blk. 7, Lot 5, Rafeli St., Chateau Ville
Subd., likewise of legal age, married, after having sworn to in accordance with law do
hereby depose and say;
That I am the absolute owner of the following motor vehicle by virtue of Deed of
Sale duly notarized dated September 7, 2012 more particularly described as follows:
MAKE/TYPE
MODEL
ENGINE NO.
CHASSIS NO.
PLATE NO.

:
:
:
:
:

NISSAN URVAN/VAN
2005
TD2Y-753945
TVP4LEFE24-A28874
XTX-379

That the following documents were lost inside the motor vehicle were I am riding
on way to Makati sometime on September 10, 2012;
1. Orig. CR/OR of the motor vehicle duly registered in favor of NOTRE DAME DE VIE
INSTITUTE of Bo. San Agustin Novaliches Proper Q.C.
2. Orig. Deed of Sale duly notarized from NOTRE DAME DE VIE INSTITUTE
(VENDOR) with Secretariat Certificate to JEORGE A. LEONARDO (VENDEE) dated
September 6, 2011.
3. Orig. Deed of Sale duly notarized from GEORGE A. LEONARDO (VENDOR) to
ALONA D. CADAG (VENDEE) dated September 7, 2012.
4. Orig. Highway Patrol Clearance Transfer of Ownership dated September 7, 2012.
5. Orig. copy of TPL insurance for LTO copy dated September 7, 2012.
6. Orig. copy of Emission Test accredited by Manila West LTO District Office.
7.
a.
b.
c.

Photo copy of Identification Card of the following:

NOTRE DAME DE VIE INSTITUTE
GEORGE A. LEONARDO
ALONA D. CADAG

That the above cited documents were placed in tact in an envelope placed besides
me on board the vehicle bound for Makati. When I alighted the vehicle I forgot to bring
my envelope.
That I exerted much effort to locate and find the vehicle, I was able to traced the
vehicle but my envelope has gone already missing.
That I executed this affidavit to attest the truth of the foregoing instrument.

ALONA D. CADAG
Affiant
SIGNED IN THE PRESENCE OF
___________________________

___________________________

REPUBLIC OF THE PHILIPPINES

)
PROVINCE OF _______________________: S.S.
CITY/MUNICIPALITY_________________)
Before me Notary Public for and the City/Municipality of ___________________
appeared with Res. Cert. No. _______________ issued on _________________ at
_______________________ known to me as the same person who executed the
foregoing instrument.
WITNESS MY HAND AND SEAL this ______ day of ______________ 2012.

Doc. No. ______

Page No. ______
Book No.______
Series of ______