REPUBLIC OF THE PHILIPPINES)

Province of Cebu ) S.S.

City of Bogo )
x----------------------------x
AFFIDAVIT OF LOSS

I, GUILLERMA S. PADUGA, of legal age, Filipino citizen, married and a resident of

Sambag, Dakit, Bogo City , Cebu, after having been duly sworn to in accordance with law,
depose and state THAT:

1. I am the wife of GALILEO CINCO PADUGA, new owner of a motor vehicle

(multicab) registered under the name of Jose Cabaral, which is particularly described as
follows:

Make & Type : Daihatsu/Pick-up

Engine Number : 3144257
Chassis Number : S82P-095167
Plate Number : GRJ-584
MV File No. : 0724-107195
CR No. : 9474863

2. The above-described motor vehicle acquired by way of a Deed of Absolute Sale

acknowledged before Notary Public Giovanny Y. Tianero, bearing Doc. No. 174; Page No. 36;
Book No. LVIII; Series of 2016;

3. As proof of ownership of the above-described vehicle, was issued by the Land

Transportation Office a Certificate of Registration (CR);

4. The said document while in my possession was misplaced and got lost and could no
longer be located in spite of diligent efforts to locate them;

5. Said document were neither transferred to other persons/entity/financial institutions

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

6. Said document were not confiscated by any government authorities for violation of
R.A. 4136 and other related laws;

7. I shall assume responsibility or liability if in any event I will use these document for
whatever illicit transactions;

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

my request to issue a New Certificate of Registration (CR) with the Land Transportation Office
(LTO).

IN WITNESS WHEREOF, I have hereunto set my hand this ___________________ in Bogo

City, Cebu, Philippines.

GUILLERMA S. PADUGA
Affiant
TIN:441-817-484-000

SUBCRIBED AND SWORN TO before me this _______________ in Bogo City,

Cebu, Philippines, affiant exhibiting to me his competent evidence of identity.

Doc. No. _____;

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