Republic of the Philippines )

City of Davao ) S.S.

AFFIDAVIT OF LOSS OR

That I, ______________________, of legal age,single Filipino, and a resident

ofMatina, Davao City, Philippines, after being duly sworn to in accordance
with law, do hereby depose and state;

1. That I am the registered owner of the motor vehicle/motorcycle

described as follows, to wit:

MAKE & TYPE OF BODY : ______________________

MOTOR NUMBER : ______________________
ENGINE NUMBER : ______________________
SERIAL/CHASSIS NO. : ______________________
PLATE NUMBER : ______________________

2. That, as proof of ownership of the above-described motor

vehicle/motorcycle I was issued by the Land Transportation Office,
Official Receipt (OR) No. ______________________ as proof of payment;

3. That the said documents while in my possessions were misplaced and

could no longer be located in spite of exerting efforts of locating them;

4. That the said documents were not in possession of any bank

institutions or lending companies by the reason of Encumbrances or
Chattel Mortgage of the subject motor vehicle/motorcycle;

5. That the said documents were not confiscated by any government

authorities in violation of R.A 4136 and other related laws;

6. That I shall assume any responsibility or liability if any event I will use
these documents for whatever elicit transactions;

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

statements and to support the same in its request for duplicate copies of
the lost MVRR/MVMRR/OR/CR at the Land Transportation Office
(LTO) where it has a hand over subject;

8. That I bind myself criminally, civilly, and administratively liable and will
surely full responsibility for any third (3rd) party claim, and I hereby
hold the Land Transportation Office or any of its employees free from
any liability arising from any claim for damages as a result of the
approval of the registration of the motor vehicle and/or issuance of
replacement certificate of registration;

IN WITNESS WHEREOF, I have hereunto set my hand this July 19,

2017 at Davao City, Philippines.

______________________
Affiant

SUBSCRIBED AND SWORN TO before me, this July 19, 2017 at Davao
City, Philippines, affiant personally appeared to me.

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