Republic of the Philippines )

Municipality of ___________)

AFFIDAVIT OF LOSS

I, ____________________ Filipino, of legal age and a resident of _________________,

Philippines, after having been duly sworn before law, do hereby depose and state:

1. That I am same person who executed this Affidavit;

2. That I am a holder of a Official Receipt (OR) and Certificate of Registration (CR) issued
by Land Transportation Office (LTO) of the motor vehicle described as the following;

MAKE: Honda TYPE: Motorcycle

MODEL: 2012 SERIAL No.: __________
MOTOR No.: ___________ PLATE No.: ____________
MV FILE No.: ___________

3. That sometimes on December 16, 2021, I lost possession of the same OR and CR;

4. That despite diligent search and efforts to locate my OR and CR, I could no longer find
the same such that I now believe that it is now lost beyond recovery;

5. As such, I execute this Affidavit to attest to the truth of the foregoing and support my
application for the re-issuance of a new OR and CR, in lieu of the one that was lost.

IN WITNESS WHEREOF, I have hereunto affixed our signatures this ____________ at

Poblacion, Sibagat, Agusan del Sur, Philippines.

________________________
Affiant
License No. ______________

SUBSCRIBE AND SWORN TO before me, this ____________ at Poblacion, Sibagat,

Agusan del Sur, Philippines, by the above affiant who are known to me personally.