REPUBLIC OF THE PHILIPPINES )

) S.S.

AFFIDAVIT OF LOSS

I, __________________, of legal age, Filipino and residing at ___________________________

__________________________, after being sworn in accordance with law, deposes and states:

1. That I am the owner of a motorcycle registered under the name of ______________ with
make and model , to wit:

Make:
Model:
Plate No:
Chasis No:

2. However, the Original Registration Certificate and other pertinent documents were lost
during the calamity brought about by Typhoon Ondoy in 2009.

3. Despite diligent effort to rummage through voluminous records kept by the owner, the
documents were not found and still remained missing. Further, there is no cogent reason to
expect that the documents will ever be found.

4. As such, I kindly request for the re-issuance of the Original Registration Certificate for
renewal thereof and proof of my ownership.

AFFIANT FURTHER SAYETH NAUGHT

AFFIANT

SUBSCRIBED AND SWORN before me this ______ day of October 2010, personally appearing and
identified by his Driver’s License (License No. ________________________) issued by the Land
Transportation Office valid until_______________________________.