AFFIDAVIT OF LOSS OF CERTIFICATE OF OWNERSHIP PAPERS OF

AUTOMOBILE

AFFIDAVIT

REPUBLIC OF THE PHILIPPINES )

CITY OF ____________________ ) S.S.

I, ____________________, of legal age, single/married, residing at _________________,

after being sworn to in accordance with law, depose and say:
1. That I am the true owner of an automobile, described as follows:
Make:
Model:
Chassis Serial No: ______
Plate No.:
2. That the said automobile had been duly registered in my name in the Land
Transportation Office in ____________________ for the year (or years) ______________;
3. That the certificate of registration and other pertinent papers of ownership of said
automobile were among those burned and destroyed on when my house and all my
personal belongings were completely destroyed by fire;
4. That said papers are now beyond recovery.

IN WITNESS WHEREOF, I have hereunto set my hand this ______ day of ______,
2______, in the City of ___________________, Philippines.

__________________________________
(Signature of Affiant)

JURAT