Republic of the Philippines)

Province of NCR) S.S.

City of Muntinlupa)
x---------x

AFFIDAVIT OF LOSS
I, CHRISTOPHER A. PINE, Filipino, of legal age, single, and
a resident of No. 5 Don Manolo Drive, Alabang Hills Village,
Alabang, Muntinlupa, Philippines, after being duly sworn in
accordance with law, depose and state:

That I am the registered owner of a certain motor vehicle,

which is more particularly described as follows:
Make: Toyota
Series: Fortuner
Type of Body: SUV
Motor No. 12345678
Chassis No.0987652
Yr. Model: 2011
Color: Black
Plate No. TSQ 728

That as a registered owner, I was issued a

Certificate of Registration (C.R.) and an Original Receipt
(O.R.) for my registration for the year 2016 by the Land
Transportation Office of Muntinlupa City, Philippines;
 That when I was about to register the said motor vehicle
for year 2017, I could no longer find said Certificate
of Registration and Official Receipt of the said motor
vehicle.
That despite diligent search and efforts to locate the said
documents, I could no longer find the same, such that I
believe that they are now lost beyond recovery.
As such, I am executing this Affidavit of Loss to attest to
the truth of the foregoing and to support my application
for the issuance of new Certificate of Registration and
Original Receipt, in lieu of the ones that were lost.

IN WITNESS WHEREOF, I have hereunto set my hand this

4th day of June 2017 in the City of Muntinlupa,
Philippines.

CHRISTOPHER A. PINE
Affiant
 JURAT
SUBSCRIBED AND SWORN to me before this 4th day of
June 2017, in the City of Muntinlupa, by CHRISTOPHER
A. PINE with Drivers License No. C92-88391092 issued
on March 7, 2015 at Muntinlupa City.

ATTY. STEPHANIE ANN A. GENER

Notary Public
My commission expires December 30, 2017
IBP Lifetime Roll No. 77930
PTR No. 5273877P, 03-7-2016,
Muntinlupa
MCLE Compliance No. V-0002332, 03-7-
2017, Muntinlupa City

Doc. No.: ___

Page No.: ___
Book No.: ___
Series of 2017.