REPUBLIC OF THE PHILIPPINES)

CITY OF ) S.S.

AFFIDAVIT OF LOSS

I, __________________________, of legal age, and a resident of

________________________________________, after having been duly sworn to in
accordance with law, do hereby depose and state, THAT:

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

described as follows:
MAKE : ENGINE NO. :
SERIES : CHASSIS NO. :
BODY TYPE : PLATE NO. :
YEAR MODEL : MV FILE NO. :
CR NO. : DENOMINATION :

2. As proof of ownership of the above-described vehicle I was issued by the

Land Transportation Office, Official Receipt (OR) No. _____________;

3. The said documents while in my possession were misplaced and could no

longer be located in spite of diligent efforts to locate them;

4. Said documents were neither transferred to other

persons/entity/financial institutions for any consideration nor
encumbered to guarantee financial obligations with any financial
institution;

5. Said documents were not confiscated by any government authorities for

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

6. I shall assume responsibility or liability if in any event I will use

these documents for whatever illicit transactions;

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

to support my request for duplicate copies of the lost
MVRR/MVMRR/OR/CR with the Land Transportation Office (LTO).

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

__________, 2020, in _______________ City, Philippines.

___________________________
Affiant
SUBSCRIBED AND SWORN to before me this _______________, at
_____________ City, Philippines, affiant exhibiting to me his Driver’s License No.
_______________, and known to me to be the same person who executed the
foregoing affidavit, and I have personally examined the affiant and I was convinced
that s/he voluntarily understood the contents thereof.

Doc. No. ___;

Page No. ___;
Book No. ___;
Series of 2020