REPUBLIC OF THE 

PHILIPPINES)
CAUAYAN CITY, ISABELA            ) S.S.
x----------------------------x
  

AFFIDAVIT OF LOSS MANUAL 

 I, CATHERINE GARCIA CALATA, of legal age, Filipino, married and a resident of
#34 National Highway, Cabaruan, Cauayan City, Isabela, 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 : 2019 MISTSUBISHI STRADA GLS
             Motor Number : 4N15UDP8367
             Type of Body: PICK-UP
Serial Number: MMBJJKK10KH024695
Plate Number: BAB5051

2. As part of the above-described vehicle, a “manual” was issued by the dealer

company;

3. The said manual while in my possession were misplaced and could no longer be
located in spite of diligent efforts to locate it;

4. Said manual were neither transferred to other persons/entity/financial institutions for

any consideration nor encumbered to guarantee financial obligations with any
financial institution;

5. Said manual 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 claim to CHARTER PING AN INSURANCE CORPORATION.

IN WITNESS WHEREOF, I have hereunto set my hand this 23rd of May

2022 in Cauayan, City, Isabela, Philippines.

CATHERINE GARCIA CALATA

Affiant
 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 2022.