REPUBLIC OF THE PHILIPPINES)

City of _______________ ) S.S.

AFFIDAVIT OF LOSS

I, ________________________, of legal age, Filipino, married, of legal age, with residence

and postal address at ___________________________, after having been sworn to in accordance
with law, freely depose and state that:

1. I am the registered owner of a motorcycle with plate number ________;

2. As proof of ownership of the above-mentioned motorcycle, I was issued

by the Land Transportation Office (LTO), __(branch)__, the Official Receipt
(O.R.) No. _________ as proof of payment and Certificate of Registration
(C.R.) No. _________ ;

3. On _______________________, while riding my motorcycle on my way home,

MMDA officer _________________ stopped me at a checkpoint and asked me to
produce the motorcycle’s O.R. and C.R.;

4. Upon checking the storage compartment of my motorcycle, I was

surprised to see that the lock was broken and that both my O.R. and C.R.
were missing;

4. I exerted all diligent efforts to locate my O.R. & C.R. but to no avail and I
therefore considered the same as lost and cannot be found;

5. I am executing this affidavit to attest to the truth of the foregoing, to

facilitate my application for the issuance of a replacement for the lost O.R.
and C.R., and for all legal purposes it may serve.

___________________________
Affiant

SUBSCRIBED AND SWORN to before me this _____ day of May ______, affiant
exhibiting to me his ________________________________, issued on _________________.

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 20___.