REPUBLIC OF THE PHILIPPINES)

CITY OF _________________ ) S.S.

x--------------------------------------------x

AFFIDAVIT OF LOSS

I, ___________________________, of legal age, Filipino, married and a resident of

______________________________________, after having been duly sworn to in
accordance with law, do hereby depose and say:

That I am a holder of a Certificate of Registration of that certain motor vehicle of

which I am the lawful and registered owner, more particularly described as follows, to
wit:

MAKE/SERIES :
BODY TYPE :
ENGINE NO. :
CHASSIS NO. :
PLATE NO. :
COLOR :

That my aforesaid Certificate of Registration was inadvertently lost through no

fault of my own and diligent efforts exerted to locate the same proved futile and to no
avail;

That the same is now beyond recovery and considered lost;

That it was not confiscated by any government or private authorities for

violation of traffic rules and regulations or for commission of any crime nor withheld
as security for payment of any debt whatsoever;

That I am executing this affidavit to attest to the truth of all the foregoing
averments for and for all legal intents and purposes.

IN WITNESS WHEREOF, I have hereunto set my hand this

______________________ at _____________________, Philippines.

__________________________
Affiant
 SUBSCRIBED AND SWORN to before me this ___________________ at
_____________________________. Affiant exhibited to me his Competent Proof of
Identity, ID No. ____________________________ issued by _______________.

Doc. No. ____

Page No. ____
Book No. ____
Series of 2021.