REPUBLIC OF THE PHILIPPINES)

DONE IN THE CITY OF BAGUIO )S.S.

x------------------------------------------x
AFFIDAVIT OF LOSS
I, ROWENA DACSIG, of legal age, Filipino, married and a resident of 257 Country Club Village, Baguio
City, Philippines, after having been duly sworn to in accordance with law, do hereby depose and state:

1. That I am the owner of a vehicle the particulars of which are:

Make: Honda
Year/Model: 2002 / CRV
Engine No: PRLD 832002825
Chassis No: PADRD 48302V002852
Color: Silver Gray

2. That the Department of Transportation issued me an OR / CR corresponding to the above

mentioned vehicle;

3. That due to a house renovation, some furniture, fixtures, and other important documents such as
the OR / CR for the above – mentioned vehicle have been relocated for the time being;

4. That because of exposure to natural elements for almost a year said furniture, fixtures, and other
important documents such as the OR / CR of the above-mentioned vehicle have corroded and
deteriorated;

5. That because of the corroded / deteriorated nature of the OR / CR the imprint therein can no
longer be read, and the document as a whole is considered damaged that it is no longer fit for its
purpose;

6. That in light of the foregoing, I now declare that the OR / CR of the above – mentioned vehicle to
be LOST BEYOND RECOVERY;

7. That further, the photocopy of the OR / CR was kept in the vehicle;

8. That because of the frequent repair of the vehicle said photocopy of the OR / CR was misplaced
during its occasional service repairs;

9. That in light of the foregoing and despite diligent search and efforts to recover the photocopy of
the OR / CR, I could not find the same such that I now declare that the same is now LOST
BEYOND RECOVERY;

10. As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing statements and
in support of my request to deactivate the said phone number and request for a new sim card
with the same sim number and for all other legal intents and purposes that it may serve.

FURTHER AFFIANT SAYETH NAUGHT.

IN WITNESS WHEREOF, I have hereunto set my hand this 15 th day of October 2020 at Baguio City,
Philippines.

ROWENA DACSIG
Affiant

SUBSCRIBED AND SWORN to before me, this 15th day of October 2020 in the City of Baguio, by the
affiant who presented to me competent proof of her identity through her PASSPORT ID bearing numbers
P0485884A Issued on 03 October 2016, issued at the City of Baguio.

ATTY. ROXANNE C. BANGASAN 

Doc No.: 213; Notary Public for Baguio City 
Page No.: 44: Not. Com. NA-NC-41-NEW-19 until Dec.31, 2020 
Book No.: II; Roll of Attorneys No. 72892; June 17, 2019 
Series of 2020. IBP Mem. No. 123789; Feb. 14, 2020; Baguio-Benguet