Republic of the Philippines ]

Province of Bohol ]
Municipality of Carmen ] S.S.

AFFIDAVIT OF LOSS
(Re: Certificate of Registration & Official Receipt)

I, JEREMIE TEJAS EMAN, Filipino, of legal age, married and a resident of

Villa Fuerte, Carmen, Bohol, Philippines, after being duly sworn in accordance with law,
hereby depose and say:

1. That I am an owner of a certain motorized vehicle specifically described as

follows:

Make: HONDA
Type: SEDAN
Plate No: YDX641
Chassis No: EK2-1004536
Motor No: D13B-2405554
OR No: 803553623
CR No: 4731692-0

2. That as such I was in possession of a Certificate of Registration and Official

Receipt for the above-described motorized vehicle;
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3. That the said Certificate of Registration and Official Receipt were in my
possession but the same was misplaced last December 2021;

4. That I exerted diligent efforts to find and recover the same, however, its
whereabouts still could not be ascertained, hence, I considered it to be lost, for
all intents and purposes;

5. That I never transferred the said Certificate of Registration and Official

Receipt to any person for consideration;

6. That I execute this affidavit voluntarily to attest to the truth of the foregoing
statements for whatever legal purpose this may serve.

IN WITNESS WHEREOF, I hereunto set my hand this 1st day of February, 2023
at Carmen, Bohol, Philippines.

JEREMIE TEJAS EMAN

Affiant
UMID: CRN-0111-2117200-7
Issued by the GSIS

SUBSCRIBED AND SWORN TO before me this 1st day of February, 2023 at

Carmen, Bohol, Philippines.