REPUBLIC OF THE PHILIPPINES)

CITY OF ILOILO) S.S.

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AFFIDAVIT OF LOSS

I, RAYVEN CAPELEÑO AGRADA, of legal age, married, and presently

residing at Westville Subdivision, Brgy. Pandac, Pavia, Iloilo after being duly
sworn to in accordance with the law do hereby depose and say THAT:

1. That I am the owner of a Certificate of Registration with CR No.

349823401 which was issued on 07 May 2019. Relative thereto, I
am also an owner of an Official Receipt with OR No. 2089301771.

2. That last 25 September 2021, when I searched my house for their

whereabouts, for purposes of conversion of my motorcycle, the
same cannot already be found;

3. That despite my diligent search and efforts to find them, the same
could no longer be found such that I now believe that they are
now lost beyond recovery.

4. That I am executing this affidavit to attest to the truthfulness of

the foregoing facts;

IN WITNESS WHEREOF, I hereunto sign this Affidavit of Loss this 01

October 2021 at Iloilo City, Philippines.

RAYVEN CAPELEÑO AGRADA

Affiant

SUBSCRIBED AND SWORN to before me, in the City of Iloilo, this 13th of
September 2021, the affiant exhibiting his duly-issued Philhealth ID with ID No.
11-050724399-1.

Doc. No. ______;

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