REPUBLIC OF THE PHILIPPINES)

CITY OF ILOILO. . . . . . . . . . . . . ) S.S.

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AFFIDAVIT OF LOSS
I, MA. TERESA A. LOS BAÑES, of legal age, married, Filipino citizen and
a resident of Brgy. Bolilao, Mandurriao, Iloilo City, Philippines, after having
been duly sworn to in accordance with law do hereby depose and say:

1. That I am a bonafide holder of one (1) Certificate of Registration pertaining

to a motor vehicle, particularly described as:

MAKE : TOYOTA VIOS 1.3E GAS M

PLATE NO. : FHH566
ENGINE NO. : 2NZ6137478
CHASSIS NO. : NCP929051220
YEAR MODEL : 2012

2. That the afore-mentioned certificate was kept inside the drawer of my

cabinet in my house although recently when needed, I can no longer find
the same;

3. That I exerted diligent efforts to look for the said certificate but to no avail
hence, I consider the same already lost and beyond recovery;

4. That I am executing this affidavit to attest to the truth of the foregoing and
to declare that the said Certificate of Registration is already lost and beyond
recovery;

5. That I am executing this affidavit for whatever legal purpose it may serve.

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

____________ 2021 in Iloilo City, Philippines.

MA. TERESA A. LOS BAÑES

Affiant

SUBSCRIBED AND SWORN to before me this _____ day of ___________

2021 in Iloilo City. Affiant personally appeared and exhibited her OSCA ID:
4762 issued in Jordan, Guimaras as competent proof of her identity and avows
under penalty of law to the whole truth of the contents of this instrument or
document.

Doc. No. ________;

Page No. ________;
Book No. ________;
Series of 2021.