AFFIDAVIT OF LOSS

REPUBLIC OF THE PHILIPPINES)

_____________________________ ) S.S.

I, JUAN DELA CRUZ, Filipino, of legal age, residing at at Bo. of San Donisio, Mun of
Paranaque, Rizal, Metro Manila, 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 : Yamaha MOTOR NO. : 123343

SERIES : Vega Force SERIAL/CHASSIS NO. : GNK2312312
TYPE OF BODY : Motorcycle PLATE NO. : KJ2312
YEAR MODEL : 2014 FILE NO. : Y2122423BJK12

(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 _________________________.

JUAN DELA CRUZ

SUBSCRIBED AND SWORN to before me, this ____ day of ______________, 20___ in
___________________ City, with affiant exhibiting his CTC No. _______________ ,
Issued on ______________________ at _________________________.
 NOTARY PUBLIC

Doc. No. : ________;

Page No. : ________;
Book No. : ________;
Series of 20_______.