Republic of the Philippines)

City of Butuan ) S.S.

AFFIDAVIT OF LOSS

I, MARIA NIEVA CUIZON MAGPULONG, Filipino, married,

with address at South Boundary, Tungkop, Minglanilla, Cebu, after having
been duly sworn according to law, hereby depose and say that:

1. I am the registered owner of a motor vehicle, particularly

described as follows:

Make/Type: SUZUKI/MOTORCYCLE
Series: GSX160DEA
Engine No.: BGA1291962
Chassis No.: NG4BA300332

2. I was issued by the Land Transportation Office an original

copy of the Original Receipt for the above mentioned vehicle;

3. However, I discovered that said original copy of the OR were

missing from my files;

3. Despite earnest efforts to locate said receipt, the same could

not be recovered anymore;

4. I am executing this affidavit to attest to the truth of the

foregoing and for whatever purpose that this may serve best.

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

________________ at _______________________________.

MARIA NIEVA CUIZON MAGPULONG

Affiant
I.D. Name:

I.D. No.:

SUBSCRIBED AND SWORN TO BEFORE ME this

__________________, affiant exhibiting to me her government issued I.D.
card with her picture and signature appearing thereon.

Doc. No. ______;

Page No. ______;
Book No. ______;
Series of 2019.