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 : MOTOR NO. :
SERIES : SERIAL/CHASSIS NO. :
TYPE OF BODY : PLATE NO. :
YEAR MODEL : 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___.