Republic of the Philippines
 Province of Negros Oriental) 


City of Dumaguete) S.S.

x---------x

AFFIDAVIT OF LOSS

I, FRANKLIN G. SALVADOR SR., Filipino, of legal age,(single / married /

widow),and a resident of Dr. V. Locsin, Taclobo, Dumaguete City, Philippines,
after being duly sworn in accordance with law, depose and state:

1. That I am the registered owner of a certain motor vehicle, which is more

particularly described as follows:

Make: Kawasaki

Series: AX125B

Type of Body: Motorcycle

Motor No.: AX125AEP87260
Chassis No.: AX125BB01332

Yr. Model: 2009
Color: 

Plate No.: 2243YY

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).
IN WITNESS WHEREOF, I have hereunto set my hand
this ___________________ in Dumaguete City, Philippines.

FRANKLIN G. SALVADOR SR.

Affiant
(Gov’t issued I.D No.)

SUBCRIBED AND SWORN TO before me this ___________________ in

_________________, Philippines, affiant exhibiting to me his competent
evidence of identity by way of __________________ issued at
______________ on __________________.

Doc. No. _____;

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