REPUBLIC OF THE PHILIPPINES)

PROVINCE OF _________________ )S.S.

MUNICIPALITY OF _____________ )

AFFIDAVIT OF LOSS

I, _______________________________________ , of legal age, single/

married, residing at ______________________________________________ ,
after being sworn in accordance with law, depose and say:

That I am the registered owner of a motor vehicle, described as

follows, to wit:

Make/Type : ___________ C.R. No. : __________

Motor No. : ___________ Current O.R. No.: __________
Chassis No. : ___________ File No. : __________
Plate No. : ___________ Classification : __________

That the said vehicle had been duly registered in my name in the
Land Transportation Office in ____________________ for the year (or years)
_________ ;

That the certificate of registration and other pertinent papers of

ownership of said vehicle were among those ____________________ on
_________________________;

That I made all possible means to locate it in all possible places

that I might have place it;

That said papers are now beyond recovery.

IN WITNESS WHEREOF, I have hereunto set my hand this

_____day of _______________________ , 20 ____, in the Municipality of
___________, Province of _______________ , Philippines.

_______________________
Affiant

SUBSCRIBED AND SWORN to before me this ____________________

at ______________________, Philippines. Affiant personally appeared
exhibiting to me his competent proof of identity as stated below his
name.