AFFIDAVIT OF LOSS

REPUBLIC OF THE PHILIPPINES) _____________________________ ) S.S.

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 SERIES TYPE OF BODY YEAR MODEL : : : : MOTOR NO. SERIAL/CHASSIS NO. PLATE NO. 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 Owners 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 _________________________. (Name Over Signature of Affiant) SUBSCRIBED AND SWORN to before me, this ____ day of ______________, 20___ in ___________________ City, with affiant exhibiting his CTC No. _______________ , Issued on ______________________ at _________________________.

NOTARY PUBLIC Until December 31, 200___ Doc. No. : ________; Page No. : ________; Book No. : ________; Series of 20___.