REPUBLIC OF THE PHILIPPINES )

PROVINCE OF CAMARINES NORTE

MUNICIPALITY OF DAET ) S.S.

AFFIDAVIT OF LOSS

I, LUIS LELIS, married, and with residence and postal address at Lot 4,
Block 10, Holiday Subdivision, Brgy. Lag-on, Daet, Camarines Norte, after
being sworn in accordance to law do hereby deposes and states, THAT:

1. I am the owner of a certain motor vehicle (acquired thru Deed of Sale)

more particularly described as follows:

MAKE HYUNDAI ENGINE NO. G4FABU157700

BODY TYPE SEDAN CHASSIS NO. KMHCT41CABU023501
YEAR MODEL 2011 PLATE NO. PQK637

2. The above-mentioned motor-vehicle was apprehended by members of

the PNP Highway Patrol Group in a checkpoint in Central Plaza
Complex, Brgy. Lag-on, Daet, Camarines Norte on November 13,
2020 for an initial violation of having delinquent registration. The
vehicle per checking with HPG’s VIMS (Vehicle Information
Management System) has an existing Hold Order (with HO No.
20130306) ;

3. Said motor-vehicle along with the original copies of the LTO Official
Receipt and Certificate of Registration (OR/CR) were impounded
and presently under the custody of the PHPT Camarines Norte:

4. I was informed that the aforementioned LTO Official Receipt and

Certificate of Registration (OR/CR)was missing or may have been
misplaced;

5. All efforts were exerted to locate or find the same but to no avail;

6. It is my honest belief that the lost LTO Official Receipt and

Certificate of Registration (OR/CR) are now lost beyond recovery;

7. I am executing this affidavit to attest that the facts mentioned herein

are true and correct to the best of my knowledge and for whatever
legal purpose this may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this 12 th day of

April 2022, in Daet, Camarines Norte, Philippines.

LUIS LELIS
Affiant
 SUBSCRIBED AND SWORN TO BEFORE ME, this 12th day of April
2022, in Daet, Camarines Norte, by the above-named affiant after exhibiting
his valid proof of identification consisting of his LTO driver’s License with No.
E01-17-0002491, valid until 2032/03/13.

Doc. No.: _______;

Page No.: _______;
Book No.: _______;
Series of 2022.