REPUBLIC OF THE PHILIPPINES)

CITY O MANILA ) S.S

AFFIDAVIT OF LOSS

I, JUAN DELA CRUZ, of legal age, Filipino, married, and with residence at 1000
Concepcion Street, Sampaloc, Manila, under oath, depose and state that:

1. I am the registered owner of one (1) unit, Honda CRV, described as follows:

Make: Honda CRV

Type: Wagon
Model: 2010
Engine No.: PNKD00-1234567
Chassis No.: PADRD01234V00098
M/V-File No.: 0987-00123456789
Manila North District Office
Plate No.: ABC-321

2. As proof of ownership of the above-described Motor Vehicle, I was issued a

Certificate of Registration (CR) No. 7654321-0 and Official Receipt (OR) No.
123456789 by the Manila North District Office of the Land Transportation Office
(LTO).

3. Said CR and OR were safely kept inside my bag; however, on 22 August 2020, my
bag was lost in transit when I traveled from Manila to my hometown in La Union.

4. I have exerted all efforts to locate my bag, but despite all the effort, I could not find
the same.

5. The original copies of the CR and OR were not assigned, mortgage, encumbered
and/or sold to any third person. The same was lost.

6. I execute this Affidavit to attest to the truthfulness foregoing facts, and to request for
duplicate copies of my lost CR and OR, and for whatever legal purpose it may
serve.

IN WITNESS WHEREOF, I have hereunto set my hand this ____ th day of

September 2020, IN Manila, Philippines.

JUAN DELA CRUZ

Affiant

SUBSCRIBED AND SWORN to before me this _____ day of September 2020 in

Quezon City Philippines. Affiant exhibited to me his competent evidence of identity as
__________________.

Notary Public

Doc. No____;
Page No. ___;
Book No. ___;
Series of 2020.