AFFIDAVIT OF LOSS

 
 
REPUBLIC OF THE PHILIPPINES)
_____________________________ ) S.S. 
                                                     
 
I, (Name of Affiant)., Filipino, of legal age, residing at (Address of Affiant), after having been sworn
in accordance with law hereby depose and state:
 
That I am the true and lawful owner of a certain motor vehicle which is more
particularly described as follows:
 
MAKE              : MOTOR NO.              :
SERIES            :  SERIAL/CHASSIS NO. :
TYPE OF BODY : PLATE NO.                :
YEAR MODEL   : FILE NO.                   :
   
 
(Change the declaration below to the actual circumstances)
 
          That sometime in June of this year, I was looking for the
original Certificate of Registration of my car but to my surprise, said Owner’s original Copy
could not found;
 
          That I took pains to look for said Certificate of Registration, but to no avail;
 
          That I am executing this affidavit to attest to the truth of the foregoing and to request
from the Land Transportation Office of Angeles City, a copy of said Certificate of Registration.
 
IN WITNESS WHEREOF, I have hereunto set my hand this _____ day of _______________. 20___ at
_________________________.
 
                  
                   
                                                                                             (Name Over Signature of
Affiant)                                           
        
 
          SUBSCRIBED AND SWORN to before me, this ____ day of ______________, 20___ in ___________________
City, with affiant exhibiting his CTC No. _______________ ,
Issued on ______________________ at _________________________.
 
 
                                                                                               NOTARY PUBLIC
                                                                                          Until December 31, 200___
 
Doc.  No. :  ________;
Page  No. :  ________;
Book No. :  ________;
Series of 20_______.