Republic of the Philippines)

Province of Negros Oriental) S.S.

CITY OF BAIS) S.S.

AFFIDAVIT OF LOSS

I, Juan De la Cruz, of legal age, single, Filipino, with residence and postal
address at Barangay I, Bais City, Negros Oriental, Philippines, after having been duly
sworn to in accordance with law, hereby depose and say, that:
I am the lawful, actual possessor and owner of a certain motor vehicle more
particularly described below as follows:

MAKE: MOTORCYCLE MV FILE NO. 07010000

BRAND: HONDA XRM PLATE NO. 917

That from the time I purchased the said motorcycle, I was in possession of its
original Certificate of Registration until the month of August 2020, when I was
transferred from Dumaguete City to Bais City to my recent assignment, when some of
my personal belongings including the certificate of registration of the above-described
motorcycle were lost in transit or have been misplaced;
That I exerted all efforts to locate and find said certificate of registration but my
efforts were futile, and the same is forever lost;
I am executing this affidavit to attest to the truthfulness of all the foregoing facts,
and for the purpose of requesting the Land Transporation Office to issue me a new
certificate of registration in lieu of the lost one.
IN WITNESS WHEREOF, I haveunto affixed my signature this 30 th day of
September 2021 at Bais City, Negros Oriental, Philippines.

JUAN DELA CRUZ

Affiant

SUBSCRIBED AND SWORN TO before me this 30th day of September 2021, in

the City of Bais, Negros Oriental, Philippines, affiant exhibiting to me his Driver’s
License with numbers GO8-007-007 to expire on 11-16-2023.

JOSE P. RIZAL
Notary Public