REPUBLIC OF THE 

PHILIPPINES)
CITY OF MAKATI            ) S.S.
x----------------------------x
  

AFFIDAVIT OF LOSS OR/CR 

 I, ___________________, of legal age, Filipino, (single/married/widow)

and a resident of _______________________________, 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 :  ______________
             Motor Number : ______________
             Chassis Number : ____________
             Plate Number : ______________
             MV File No. : ________________
             Year Model/Color : ___________

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 Makati City, Metro Manila, 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 2013.