REPUBLIC OF THE PHILIPPINES )

PROVINCE OF DAVAO DEL NORTE ) SSS

ISLAND GARDEN CITY OF SAMAL )

AFFIDAVIT OF LOSS OR/CR

I, __________________________________, of legal age, Filipino,
single/married/widow/widower/separated and a resident of __________________
_______________________, after having been duly sworn to pursuant to law, depose and
say:
1. That I am the registered owner of the motor vehicle described below as, to wit:
Make & Type :
Motor Number :
Chassis Number :
Plate Number :
2. That , as proof of ownership of the above described vehicle I was issued by the Land
Transportation Office, Official Receipt (OR) as proof of payment and Certificate of
Registration (CR);
3. That the said documents while in my possession were misplaced and could no
longer be located inspite of exerting efforts of locating them;
4. That the said documents were not in the possession of any bank institutions or
lending companies by reason of encumbrances or chattel mortgage of the subject motor
vehicle;
5. That the said documents were not confiscated by any governments authorities in
violation of R.A. 4136 and other related laws;
6. That I shall assume responsibility or liability if in any event I will use these
documents for whatever illicit transactions;
7. That I am executing this affidavit to attest to the veracity of my statements and to
support the same in its requests for duplicate copies of the lost MVRR/MVMRR/OR/CR at
the Land Transportation Office (LTO) where it has a hand over subject.
8. That I bind myself criminally, civilly and administratively liable and will assume full
responsibility for any 3rd party claim, and hereby hold the Land Transportation Office or any
of its employees free from any liability arising from any claim for damages as a result of the
approval of the registration of the motor vehicle and or issuance of replacement certificate
or registration.
IN WITNESS HEREOF, I have hereunto set my hand this _____________ in Babak,
Island Garden City of Samal, Philippines.

________________________
Affiant
Res. Cert. No. _____________
Issued at _________________
On _________________ 2012
SUBSCRIBED AND SWORN to before me this _______________ in Babak, Island
Garden City of Samal, Philippines, affiant exhibited to me her residence certificate, number
of which is clearly written as above indicated.

MARDOCHEO S. CAMPOREDONDO
Notary Public
Doc. No. _______; Until December 31, 2013
Page No. _______; PTR No. 4186724 issued at Samal City
Book No. _______; on January 2, 2012
Series of 2012. TIN 880-114-418-669