REPUBLIC 

OF THE PHILIPPINES)
CITY OF CAGAYAN DE ORO      ) S.S.
x----------------------------x
  

AFFIDAVIT OF LOSS CR 

 I, Nikki Lou U. Densing , of legal age, Filipino, single and a
resident of #28 Zone 8 Cugman, Cagayan de Oro City, after
having been duly sworn to in accordance with law, depose and
state THAT:

1. I am the registered owner of a motor vehicle which is particularly

described as follows:
    
             Make & Type :  HONDA MOTORCYCLE
  Motor Number : XRM18026270             
Chassis Number : XRM18EO26281
             Plate Number : 9111KV
             MV File No. : 
             Year Model/Color : :XRM OR FRAME/RED

2. As proof of ownership of the above-described vehicle I was issued

by the Land Transportation Office, Official Receipt (OR) and
Certificate of Registration (CR);

3. The said documents while in my possession were misplaced and

could no longer be located in spite of diligent efforts to locate
them;

4. Said documents were neither transferred to other

persons/entity/financial institutions for any consideration nor
encumbered to guarantee financial obligations with any financial
institution;
5. Said documents were not confiscated by any
government authorities for violation of R.A. 4136 and other
related laws;

6. I shall assume responsibility or liability if in any event I will use

these documents for whatever illicit transactions;

7. I am executing this affidavit to attest to the veracity of my

statements and to support my request for duplicate copies of the
lost MVRR/MVMRR/OR/CR with the Land Transportation Office
(LTO).

IN WITNESS WHEREOF, I have hereunto set my hand

this ___________________ in Cagayan de Oro
City, Philippines.

____________________
Affiant
SSS ID No. _____________

 SUBCRIBED AND SWORN TO before me

this ___________________ in
_________________, Philippines, affiant exhibiting to me his/her
competent evidence of identity by way of __________________
issued at ______________ on __________________.

Doc. No. _____;

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