Republic of the Philippines )

Dumaguete City ) S.S.

Negros Oriental

AFFIDAVIT OF LOSS

I, JENNIFER PANA CUEVAS, of legal age, Filipino, single, and a resident of

Purok Malinawon, Brgy. Talay, Dumaguete City, subscribing under oath, hereby depose
and state:

1. That I am the holder of a CERTIFICATE OF REGISTRATION with C.R. No.

191756357 issued by the Land Transportation Office;

2. That sometime on April, 2016, I misplaced the said CERTIFICATE OF

REGISTRATION;

3. That despite diligent search and efforts to locate the said CERTIFICATE OF
REGISTRATION, I could not find it such that I now believe that it is lost beyond
recovery;

4. As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
and to support my application to renew the vehicle’s denomination from single
(without side car) to one having side car.

In witness whereof, I have hereunto set my hand this ____________ at Dumaguete

City, Philippines.

JENNIFER PANA CUEVAS

Affiant
Identification Card: Postal Identity Card
Identification Card No.: K26180659222 P

ACKNOWLEDGMENT

SUBSCRIBED and SWORN to before me this ____ day of May, 2019, personally
appeared Affiant who is known to me and identified by me by competent evidence of
identity in accordance with the 2004 Rules on Notarial Practice, who exhibited to me the
above identification card, who executed this foregoing Affidavit of Loss and
acknowledged that the same is her free and voluntary act and deed. This instrument
consisting of one page, including this page whereon this acknowledgement is written
has been signed by Affiant.

            IN WITNESS WHEREOF, I have hereunto affixed my signature and notarial seal
this _____ day of May, 2019 in Dumaguete City, Philippines.

Doc. No._____
Page No.____
Book No. ____
Series 2019.