Republic of the Philippines)

Masbate City )

AFFIDAVIT OF LOSS

I ___________________, of legal age, filipino, single and with residence address

at ______________________ after being duly sworn, hereby depose and say that:

1. I am the registered owner of a motor vehicle, specifically described as follows:

Model or Type:

Plate Number:

Chasis Number:

2. That sometime on _____________, I discovered that my bag containing the

original copy of the Certificate of Registration (CR) issued by the Land Transportation
Office-Masbate City (LTO) was lost during one of my travels in Masbate City;

3. That I tried to locate the same but my efforts proved futile, thus, said original
copy of the Certificate of Registration (CR) issued by the Land Transportation
Office-Masbate City (LTO) should be considered lost for all intents and purposes.
IN WITNESS WHEREOF, I am executing this Affidavit to attest the truth of the
foregoing facts this 19th day of March 2021, at Masbate City, Philippines.

Affiant

SUBSCRIBED AND SWORN TO BEFORE ME, THIS 19 TH day of March 2021 at

Masbate City, Philippines.

Doc No.
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