REPUBLIC OF THE PHILIPPINES )

GUAGUA, PAMPANGA ) S.S.

AFFIDAVIT OF LOSS

I, __________________________________________, of legal age, Filipino Citizen,

with residence at ___________________________________________________________
after having been duly sworn in accordance with law, do hereby depose and state:

1.) That I am the owner of a certain motor vehicle, which is more particularly
described as follows:
MAKE AND TYPE : ____________________________________________
MOTOR NO. : ____________________________________________
CHASSIS NO. : ____________________________________________
PLATE NO. : ____________________________________________
FILE NO. : ____________________________________________
2.) That the original Certificate of Registration and Official Receipt which was issued
by the LAND TRANSPORTATION OFFICE of the above – mentioned vehicle was lost when I
went to Guagua Public Market in Guagua, Pampanga to purchase for my daily food consumption
but when I was about to pay for the goods that I bought, I found out that my wallet was missing
and I tried to locate and find it, but to no avail;

3.) That the said Certificate of Registration and Official Receipt was not mortgaged
to any lending institution as collateral and was never confiscated by any government authorities
for violation of traffic rules and regulations;

4.) That I am willing to undertake and assume full responsibility in the event of any
third party claim against the motor vehicle and shall defend my right over the same;

5.) That I hold the LAND TRANSPORTATION OFFICE free from any form of
obligation and absolving the former and its personnel from any liabilities arising thereto and
warrant said Certificate of Registration and Official Receipt free from all liens and
encumbrances; and

6.) That I am executing this Affidavit to attest the truth of the foregoing facts and to
inform the government agencies concerned regarding the loss of the aforementioned documents.

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

___________________ at Guagua, Pampanga.

__________________________________
AFFIANT

Identification Document ___________________________________________________

SUBSCRIBED AND SWORN to before me on this ______ day of

_______________________ at Guagua, Pampanga. Affiant exhibited to me his Identification
Document stated below his name.

Doc No. ______

Page No. _____
Book No. _____
Series of 20__.