Republic of the Philippines )

Province of Agusan del Sur )s.s.

City of Bayugan )

AFFIDAVIT OF LOSS

I, ESPERIDION T. OROPA, of legal age, Filipino, married and resident of

Crossing Maygatasan, Bayugan City, Agusan del Sur, Philippines, after having been duly
sworn to in accordance with law do hereby depose and say:

1. That I am the same person executing this affidavit;

2. That I am the holder of certain Official Receipt (OR) and Certificate of
Registration (CR) issued to me by the LTO;
3. That sometime on December 29, 2014, said OR and CR was lost while in my
possession;
4. That after diligent search of the places where I could have possibly placed the said
OR and CR, the same could no longer be found anymore;
5. That I am executing this affidavit in order to attest to the truth of the foregoing
circumstances.

IN WITNESS WHEREOF, I have hereunto set my hand this ____day of

___________, 20__ at Bayugan City, Agusan del Sur.

ESPERIDION T. OROPA
Affiant

JURAT

SUBSCRIBED AND SWORN to before me this ___ day of ___________ 20__,

at Bayugan City, Agusan del Sur, Philippines.

ATTY. GERARDO M. LABASTILLA

Notary Public
Until December 31, 2015
PTR No. 5881816 Issued On. 01-06-2015
IBP No. 953193 Issued on: 01-06-2015
ROLL NO. 49777
Doc. No. ______
Page No. ______
Book No. ______
Series of 2014.