REPUBLIC OF THE PHILIPPINES)

) S.S.

AFFIDAVIT OF LOSS OR/CR

OF A MOTOR VEHICLE
I, ___________________, of legal age, Filipino,
(single/married/widow) and a resident of
_______________________________, 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 : ______________

Motor Number : ______________
Chassis Number : ______________
Plate Number : ______________
MV File No. : ______________
Year Model/Color : ______________

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).

FURTHER, I SAYETH NONE.

__________________________________
Affiant
Gov’t Issued I.D. No. _____________

SUBSCRIBED AND SWORN to before me this ___ day of

__________________ 2023, affiant exhibited to me his Government Issued I.D.
number written below her name.

Doc. No. ____; NOTARY PUBLIC

Page No. ____;
Book No. ____;
Series of 20____.