REPUBLIC OF THE PHILIPPINES )

CITY OF LAOAG ) s.s.

AFFIDAVIT OF LOSS

I, CRISPIN S. SOMERA, of legal age, Filipino and a resident of

Baclig (Poblacion), Cabugao, Ilocos Sur, Philippines, after having been
duly sworn to in accordance with law hereby voluntarily depose and
state: That-

1. I am a holder of an original Official Receipt issued by the Land

Transportation Office (LTO) covering a utility vehicle which is
more particularly described as follows:

MV File No.: 1366-00000099434 Body Type: WAGON

Engine No.: 4JA1BG6219 Make: ISUZU
Chasis No.: PABTBRS4F32017124 Year Model: 2003
Plate No.: XJR 716 Series: Hilander

2. I always keep the said original Official Receipt in my personal

cabinet inside our house;

3. Sometime in December, 2017, I discovered that the said

original Official Receipt is no longer in the place where it was
kept;

4. I exerted diligent efforts to locate the said original Official

Receipt but to no avail. Hence, the said original Official Receipt
is now deemed lost; and

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

foregoing facts and hereby ask the proper authorities to issue
me replacement for the Official Receipt in lieu of the lost one.
This affidavit is also executed for whatever legal purpose it
may serve

IN WITNESS WHEREOF I have hereunto set my hand this July 26,

2018 at Laoag City, Philippines.

CRISPIN S. SOMERA
Affiant
ID No. _______________

SUBSCRIBED AND SWORN to before me this July 26, 2018 at

Laoag City, Philippines. Affiant exhibiting to me his identification card
indicated below his name.