REPUBLIC OF THE PHILIPPINES )

PROVINCE OF PAMPANGA ) S.S

CITY OF SAN FERNANDO )

AFFIDAVIT OF LOSS

I, GERTRUDES D. CANLAS, of legal age, widow, Filipino citizen, with postal

address at Purok 1, San Pablo Proper, San Simon, Pampanga, after having been
deposed in accordance with law, do hereby state.

1. That I am a holder and the owner of the Certificate of Registration of motor

vehicle described as follows:

Make: REBUILT YEAR MODEL 2004

Body Type: JITNEY Engine No.: 4D32-491761
Chassis No.: Plate No.: RAM160
RSS-200427003-C
Series: FUSO MV File No: 0380-00000071444

And also the Official receipt of the above-mentioned with O.R No. 1749886552
which was issued on October 25, 2019;

(As evidence, attached herewith is the photo copy the Certificate of Registration
and Official receipt, marked as Annex “A”)

2. That unfortunately sometime on October 2020, I cannot find the original copy of
my motor vehicle;

3. That these documents were placed inside an envelope and kept inside my
cabinet;

4. That I tried to find them but to no avail;

5. That I can no longer find the said documents and the same were already
missing;

6. That for all legal intents and purposes, I considered the same as lost;

7. That I am, executing this affidavit to attest to the fact that the said documents
mentioned above that were issued to me are now missing and beyond recovery
despite my best efforts to retrieve them and also to request to issue an original
copy of the said motor vehicle before the Land Transportation Office;
IN WITNESS WHEREOF, I have hereunto signed my signature this
_________________________ at City of San Fernando, Pampanga.

GERTRUDES D. CANLAS
AFFIANT
Senior ID No: SPP03021

SUBSCRIBED AND SWORN to before me this ___________________at City of San

Fernando, Pampanga and showing to me his ID No.____________________ issued at
________________________.

Doc. No _______; ATTY. SHAIN ANN C. CASTILLO

Page No._______; NOTARY PUBLIC
Book No._______ IBP No. 3571737 /01-08-2020
Series of 2020. PTR NO. 102217 / 12-30-2019

Roll No. 71234;

MCLE Compl. No. V1-0015854
Valid until 04 -14 – 2022
CP No.09199628526
Unit 5, 2nd Floor, MDLD Bldg.,
Brgy., San Nicolas, San Fernando,
Pampanga