REPUBLIC OF THE 

PHILIPPINES)
CITY OF SURIGAO                ) S.S.
x---------------------------------------x

AFFIDAVIT OF LOSS

      I, IZRA MATTHEW T. SERVIN, of legal age, single, Filipino,

and resident of Poblacion, Salvador, Lanao del Norte, after having
been duly sworn to oath, hereby depose and state:

1. That I am a registered owner of a motorcycle having been

issued by LTO of R10 (New Registration Unit).

2. That I seek to renew the Certificate of Registration (bearing No.

36322570-4) and Official Receipt (No. 1734936195) to my
vehicle which needs presentation thereof at the LTO;

3. That unfortunately, I could not present the original copies

thereof since I could longer locate or retrieve the same
(OR/CR) among my personal files and I could no longer
remember the exact circumstances surrounding its loss.
However, what remained are only the faithful reproductions or
photocopies thereof (attached hereof) as proof that I was
previously issued such documents by said LTO office.

4. That in view of the foregoing, I hereby declare the original

copies of my OR and CR as permanently lost or missing for
all intents and purposes, particularly so that I may apply for
its immediate renewal at the LTO office here in Surigao City
where I am currently located; and for whatever legal purpose it
may serve.

IZRA MATTHEW T. SERVIN

Affiant
Valid ID: LTO Lic. No. K07-20-002589
Valid until : 08/24/2024

SUBSCRIBED and SWORN to before me this ___ day of January 2021 in

Surigao City, with the affiant who exhibited to me his valid ID indicated above
issued by Philhealth, serving as competent proof of his identity.

Doc. No._______
Page No. ______
Book No.______
Series of 2020