Affidavit of Loss of Certificate of Ownership Papers of Automobile

AFFIDAVIT

REPUBLIC OF THE PHILIPPINES

PROVINCE OF _________________ SS
MUNICIPALITY OF _____________

I, _______________________________________ , of legal age, single / married,

residing at ______________________________________________ , after being sworn
in accordance with law, depose and say:

That I am the true owner of an automobile, described as follows, to wit:

Make/Type : ___________ C.R. No. : __________

Motor No. : ___________ Current O.R. No.: __________
Chasis No. : ___________ File No. : __________
Plate No. : ___________ Classification : __________
Trade Name : ________________

That the said automobile had been duly registered in my name in the Motor
Vehicle Office in ____________________ for the year (or years) _________ ;

That the certificate of registration and other pertinent papers of ownership of said
automobile were among those burned and destroyed / loss in an earthquake / robbed on
_________________________;

That I made all possible means to locate it in all possible places that I might have
place it;

That said papers are now beyond recovery.

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

_______________________ , 20 ____, in the Municipality of ___________, Province of
_______________ , Philippines.

_______________________
(Signature of affiant)

SUBCRIBED AND SWORN to before me in the Province of La Union, Municipality of

Agoo, Philippines, this 7th day of July at 2007. Affiant having exhibited to me his
Community Tax Certificate No. 777-3333 issued on January 11, 2007 at Agoo, La Union.

ATTY _________________________________
Doc. No. 123 COMMISSION NO. _____________________
Page No. 69 NOTARY PUBLIC for AGOO, LA UNION
Book No. VII UNTIL DECEMBER 31, 2007
Series of 2007 OFFICE: 9 Cases Blvd. Brgy Sta Barbara, Agoo La Union
ROLL NO. 00001
IBP NO. 1234567 ; 01/07/07 ; LA UNION
PTR NO 1234567 ; 01/07/07 ; LA UNION
MCLE COMPLIANCE No. __________; July 7, 2007