REPUBLIC OF THE PHILIPPINES )

CITY OF TUGUEGARAO ) S.S.

x-------------------------------------------------x

AFFIDAVIT OF LOSS OR/CR

I, _______________, of legal age, Filipino, married and a resident of

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

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

follows:
    
Make & Type : __________________
Engine Number :  __________________
Chassis Number : __________________
Plate Number : __________________
Model : __________________
Year Model/Color : __________________

2. As proof of ownership of the above-described vehicle, my father was issued by

the Land Transportation Office, Official Receipt (OR) and Certificate
of Registration (CR);

3. The above-described vehicle was used by me since ________;

4. The OR and CR issued by the LTO while in my possession were misplaced and
could no longer be located in spite of diligent efforts to locate them;

5. Said documents were neither transferred to other persons/entity/financial

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

6. Said documents were not confiscated by any government authorities for violation
of R.A. 4136 and other related laws;

7. I shall assume responsibility or liability if in any event I will use these documents
for whatever illicit transactions;

8. 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 ___________________ in

Tuguegarao City, Cagayan.

_________________________
Affiant
Valid ID No. _____________

SUBCRIBED AND SWORN TO before me this ___________________ in Tuguegarao City,

Cagayan.

Doc. No. _____;

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