AFFIDAVIT OF LOSS OR/CR 

  
KNOW ALL MEN BY THESE PRESENTS:
  
I, ALMONCHITO AMANTE DAROYA, of legal age, Filipino, and a resident of 312
Cluster 3 Flexihomes Brgy. Rosario Pasig City, 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 :   TOYOTA Vios 1.3 Plate Number: UIJ194
    Engine Number :  2NZ6196620 Chasis No.:  NCP929052675
    MV File No. :  132800000270294 Year Model/Color :  2012
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 ___________________ in ____________________, Philippines.

ALMONCHITO AMANTE DAROYA

Affiant

Republic of the Philippines )

                                        ) S.S
 
BEFORE ME, personally appeared:
 
Known to me and to me known to be the same persons who executed the foregoing
instrument and acknowledged to me that the same is their free and voluntary act and
deed.
 
WITNESS MY HAND AND SEAL, on the date and place first above written.
                                                                  
                                                                                     Notary Public
 
Doc. No.______;
Page No. ______;
Book No.______;
Series of 20___.