REPUBLIC OF THE PHILIPPINES )

PROVINCE OF CEBU ) s.s.

MUNICIPALITY OF CARMEN )

AFFIDAVIT OF LOSS OR/CR

I, __________________________________, of legal age, Filipino,

single/married/widow/widower/separated and a resident of __________________
_______________________, after having been duly sworn to pursuant to law, depose and say,
THAT:

1. I am the registered owner of the motor vehicle described below as, to wit:

Make & Type :

Motor Number :
Chassis Number :
Plate Number :

2. As proof of ownership of the above described vehicle I was issued by the Land
Transportation Office, Official Receipt (OR) as proof of payment and Certificate of Registration
(CR);
3. The said documents while in my possession were misplaced and could no longer be
located inspite of exerting efforts of locating them;
4. The said documents were not in the possession of any bank institutions or lending
companies by reason of encumbrances or chattel mortgage of the subject motor vehicle;
5. The said documents were not confiscated by any governments authorities in violation of
R.A. 4136 and other related laws;
6. I shall assume responsibility or liability if in any event I will use these documents for
whatever illicit transactions;
7. I am executing this affidavit to attest to the veracity of my statements and to support the
same in its requests for duplicate copies of the lost MVRR/MVMRR/OR/CR at the Land
Transportation Office (LTO) where it has a hand over subject.
8. I will assume full responsibility for any 3 rd party claim, and hereby hold the Land
Transportation Office or any of its employees free from any liability arising from any claim for
damages as a result of the approval of the registration of the motor vehicle and or issuance of
replacement certificate or registration.

IN WITNESS HEREOF, I have hereunto set my hand this 30 th of September 2020, in

Carmen, Cebu, Philippines.

________________________
Affiant

SUBSCRIBED AND SWORN to before me this 30th of September 2020, in Carmen,

Cebu, Philippines, affiant exhibited to me her residence certificate with CTC number
_____________________________.

Doc. No.: _____; ATTY. MERIAN V. BUOT

NOTARY PUBLIC
Page No.:_____;
Book No.:_____;
Series of 2020.