REPUBLIC OF THE PHILIPPINES)

CAUAYAN CITY ) S.S.

x-----------------------------------------------x

AFFIDAVIT OF LOSS

I, GILBERT ALDANA GALOPE of legal age, Filipino, married and a

resident of Kensington Heights, Cabarauan, Cauayan City, Isabela after
having been duly sworn to in accordance with law, depose and state THAT:

1. I am the registered owner of a motor vehicle which is particularly described

as follows:

Make & Type : HONDA CITY

Motor Number : 3453150
Chassis Number : PADG142440
Plate Number : AAA 2529
MV File No. : E443302
Year Model/Color : 2014 Urban Titanium

2. As proof of ownership of the above-described vehicle I was issued by

the Land Transportation Office, Official Receipt (OR) and Certificate of
Registration (CR);

3. The said documents while in my possession were misplaced and could no

longer be located in spite of diligent efforts to locate them;

4. Said documents were neither transferred to other persons/entity/financial

institutions for any consideration nor encumbered to guarantee financial
obligations with any financial institution;

5. Said documents were not confiscated by any government authorities

for violation of R.A. 4136 and other related laws;

6. I shall assume responsibility or liability if in any event I will use these

documents for whatever illicit transactions;

7. I am executing this affidavit to attest to the veracity of my statements and

to support my request for duplicate copies of the lost
MVRR/MVMRR/OR/CR with the Land Transportation Office (LTO).

GILBERT A. GALOPE
Affiant
PASSPORT No. EC0336857

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BEFORE ME, appears the person of GILBERT A. GALOPE presenting the
above Affidavit, who is personally known to me or identified by me through
competent evidence of identity as defined by the Notarial Rules as the person
who signs the document and in my presence taken an oath or affirmation
before me as to such document.

WITNESS MY HAND AND SEAL this 6th day of December, 2017 in

Cauayan City, Isabela.

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 2017.

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