Republic of the Philippines )

City of Tacloban )S.S.

AFFIDAVIT OF LOSS

I, AMELITO P. UMACOB, Filipino, of legal age, married, and with residence at #77
Kalipayan Rd., Brgy 62-B Sagkahan, Tacloban City, after being duly sworn to in
accordance with law, hereby depose and state:

1. That I am the registered owner of a certain motor vehicle, which is more particularly
described as follows:

Make & Type: ;

Motor Number: ;
Chassis Number: ;
Plate Number: ;

2. That as proof of ownership of the above-described motor vehicle, I was issued by

the Land Transportation Office (LTO) an Official Receipt (OR) as proof of payment
and a Certificate of Registration (CR);

3. That the said documents, while in my possession, were misplaced and could no
longer be located despite diligent search and effort and as such, I now believe that
it is now lost beyond recovery;

4. That the said documents are not in the possession of any bank institutions or
lending companies by reason of encumbrances or chattel mortgage of the subject
motor vehicle;

5. That the said documents were not confiscated by any government authorities in
violation of R.A. 4136 and other related laws;

6. As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
and for purposes of applying for renewal of registration.

IN WITNESS WHEREOF, I have hereunto set my hand this 19th day of September
2019 at Tacloban City, Philippines.

AMELITO P. UMACOB
Affiant
Valid ID No. ____________

SUBSCRIBED AND SWORN to before me this ________________ in Tacloban

City, affiant exhibiting to me his competent evidence of identity as indicated above.

WITNESS MY HAND AND SEAL.

Doc. No. _____;

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