REPUBLIC OF THE PHILIPPINES)

PROVINCE OF ALBAY ) S.S.

TABACO CITY )
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 ____ day of ___________
20____ in ____________, _____________, Philippines.

___________________________________

Affiant

SSS ID No. _____________

SUBSCRIBED AND SWORN to before me, this ____ day of __________ 20____, in
the City of __________________, by ___________________ with Passport
No.________________ issued on __________________ at _____________.

ATTY. ANTHONY CLARK A. GAPIDO

Notary Public Tabaco City
For the Province of Albay
Roll No. 83746
IBP OR No. 227570; June 13, 2022
PTR No. 8843533; July 13, 2022 at Tabaco City
MCLE: N/A (Newly Admitted to the Bar)
2nd Floor Coastal Building Rental, Purok 2,
Morales Street, San Roque,Tabaco City, 4511

Doc No.____;
Page No. 450;
Book No. 35 ;
Series of 2022