REPUBLIC OF THE PHILIPPINES | S. S.

DONE: IN THE ___________________ |

AFFIDAVIT OF LOSS

I, _____________________, of legal age, married, Filipino, and with residence address at

_______________________________, Philippines, after being sworn in accordance with law,
hereby depose and state—

1. I am the true and registered owner of a ________________ motor vehicle registered

with the Land Transportation Office [LTO]. In connection with this, I was issued a Certificate of
Registration [CR] by the LTO.

2. The said motor vehicle was initially mortgage with ________________________.

After I fully paid the loaned amount, the bank issued to me a Release of Chattel
Mortgage/Cancellation of Chattel Mortgage relative to the full payment of the Promissory Note
with Chattel Mortgage under PN No. _________________________ annotated on the Certificate
of Registration [CR] of the said motor vehicle. I also caused the registration of said Release of
Chattel Mortgage/Cancellation of Chattel Mortgage with the Registry of Deeds for
_________________________.

3. Last ____________________, I discovered that said Release of Chattel

Mortgage/Cancellation of Chattel Mortgage as well as the Promissory Note with Chattel
Mortgage already registered with the Registry of Deeds for ______________________ were
missing. Despite of diligent search and efforts, the same could no longer be found in my files.
All my efforts to locate and retrieve it were in vain. Hence, for all legal intents and purposes it is
now deemed lost and beyond recovery.

4. I certify and confirm that the said Release of Chattel Mortgage/Cancellation of

Chattel Mortgage as well as the Promissory Note with Chattel Mortgage were neither confiscated
by, nor relinquished in favour of, any person, whether natural or juridical, or with any
government office, agency, entity or authority.

5. I attest to the truth of the foregoing statements to the best of my own personal
knowledge and based on authentic documents or records. I am executing this Affidavit of Loss to
support my application with the ______________________________ to issue unto me a new
Release of Chattel Mortgage/Cancellation of Chattel Mortgage as well as the Promissory Note
with Chattel Mortgage in lieu of the ones that were lost and for all other lawful intents and
purposes it may serve.

IN WITNESS WHEREOF, I set my hand this ___ day of __________________ at

______________________, Philippines.

___________________________
Affiant

SUBSCRIBED AND SWORN to before me this ____ day of _________________ at

_______________________, Philippines.

Doc. No.
Page No.
Book No.
Series of 2023