Republic of the Philippines )

DONE: CITY OF BAGUIO ) SS.

AFFIDAVIT OF LOSS
I, LITO Q. CAMORA, of legal age, single, Filipino Citizen with residence and postal
address at Jappa, Shilan, La Trinidad, Benguet, Philippines, after having been duly sworn to in
accordance with law do hereby depose and state:
1. That I am an owner of a Motor Cycle, RUSI, and was issued a KEY;
2. That however, the said KEY was destroyed (it was cut into pieces) and I went to the Office
of RUSI and was issued another KEY for my Motorcycle, unfortunately, said KEY, just like the
first, it was destroyed again, thus I cause the duplication of the KEY;
3. That said destroyed KEYS were lost, it was misplaced in my house and though I exerted
diligent efforts to locate such KEYS, but the same could no longer be found, hence, considered
forever lost;
5.The said TWO (2) KEYS has not been given nor pledged to anyone for any purpose
whatsoever, nor was it taken or confiscated by the authorities for any violation of any law or
traffic law or regulations;
6. That I am executing this affidavit to attest to the truthfulness of the foregoing facts and for
all legal intents and purposes that it may serve.
IN WITNESS WHEREOF, I have hereunto set my hand this 13 th day of November,
2013 at Baguio City, Philippines.
LITO Q. CAMORA
Affiant
PhilHealth ID No. 04-224023815-7
SUBSCRIBED AND SWORN TO before me this 13th day of November, 2013 at Baguio
City, Philippines. Affiant personally appeared before me to be the same person who executed this
instrument as her free act and deed.
Doc. No. 081;
Page No. 17;
Book No. 6;
Series of 2013.