REPUBLIC OF THE PHILIPPINES)

PROVINCE OF QUEZON )S.S.

MUNICIPALITY OF LOPEZ )

AFFIDAVIT OF LOSS CERTIFICATE OF

REGISTRATION OF VEHICLE WITH NON-MORTGAGE
THAT I, WILLIAM A. DE MESA, of legal age, married/single/widow/er, Filipino citizen, and
a resident of Brgy. Mayao Parada, Lucena City after having been duly sworn to in accordance
with the law, depose and say;

1. That I am the registered and absolute owner of a certain vehicle particularly described as
follows:
MAKE AND BODY TYPE:
MOTOR NUMBER:
CHASSIS NUMBER:
PLATE NUMBER:
MV FILE NUMBER:
CERTIFICATE OF REG. NO.:

2. That recently, the original copy of the Certificate of Registration/Official Receipt of the
above-described vehicle was misplaced/fell down in the street without my knowledge
consequently, the same it was lost;

3. That I exert diligent effort to locate the same, but to no avail;

4. That the said original copy of the Certificate of Registration/Official Receipt of the
vehicle described above was not confiscated for violation of any traffic laws, rules and
regulations nor for violation of the rules and regulations being implemented by the
Land Transportation Office;

5. That the vehicle covered by the said Certificate of Registration/ Official Receipt was
not mortgaged to any third person/s entity/ies and to any banking/lending institution;

6. That I execute this affidavit to attest the fact of loss of the said original copy of the
Certificate of Registration/ Official Receipt of the vehicle described above; and this
affidavit may be used for whatever legal purpose it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand and affixed my signature this_____day
of_______, at Lopez, Quezon, Philippines.

_________________________
Affiant
I.D No.:___________________
Issued by:_________________
Valid until:________________
SUBSCRIBED AND SWORN to before me this______day of____________ at Lopez, Quezon,
Philippines.

Doc. No.___
Page No.___ FRANCIS EDGARDO G. LAVARRO
Book No.___ Notary Public
Series of 2023 Commission Expires: December 31, 2023
Roll of Attorney No. 78537, May 13, 2022
IBP No. 252794;Dec. 23, 2022, Pasig City
PTR No. 3138402
Jan. 03, 2023, Lopez, Que.
MCLE Compliance No. Newly Admitted