REPUBLIC OF THE PHILIPPINES )

CITY OF __________ ) S.S.

x------------------------------------------x

AFFIDAVIT OF LOSS

I, ____________________________, of legal age, married, residing at

____________________________, after being sworn to in accordance with law, hereby depose
and say:

1. That I am the owner of a motorcycle, described as follows:

Make:
Model:
Color:
Chassis Number:
Engine Number:
Plate Number:

2. That the said motorcycle had been duly registered under my name in the Land
Transportation office in _________________;

3. That the Certificate of Registration of said motorcycle were among those that was lost
on _______________ during the___________________;

4. That I exerted efforts to locate the same but to no avail;

5. That the said Certificate of Registration is now beyond recovery;

6. That I am executing this affidavit to attest to the truthfulness of the foregoing facts and
circumstances and to use the same for request of re-issuance of a new Certificate of
Registration.

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

______ in the __________________________.

________________________
(Signature of Affiant)

SUBSCRIBED AND SWORN to before me this _____________

at__________________. Affiant exhibiting to me his ID bearing No._________, issued at
__________________.