REPUBLIC OF THE PHILIPPINES)

CAGAYAN DE ORO CITY ) S.S

AFFIDAVIT OF LOSS OR/CR

I, XXXXX of legal age, Filipino, and a resident of XXXX, Philippines, after having been duly
sworn to according to law, hereby depose and state:

1. That I am the registered owner of a motor vehicle which is described as follows:

CR NO. : BODY TYPE :

OR NO. : ENGINE NO. :
MAKE : PLATE NO. :
SERIES : MV FILE :

2. That as proof of ownership of the above-described vehicle I was issued by the Land
Transportation Office, an Official Receipt (OR) and Certificate of Registration (CR);
3. That said documents while in my possession were misplaced and could no longer be
located in spite of diligent efforts to locate them;
4. That said documents were neither transferred to other persons/entity/financial
institutions for any consideration nor encumbered to guarantee financial obligations
with any financial institutions;
5. That said documents were not confiscated by any government authorities for
violation of R.A. 4136 and other related laws;
6. That I am executing this Affidavit of Loss to attest to the truth of the foregoing facts
and to request for the duplicate copies of my lost CR and OR and for whatever legal
purpose it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this XXth day of XXXX 202_ at the
Cagayan de Oro City.

XXXXXXX
Driver’s License No: XXXXXX
Valid until: XXXX

SUBSCRIBED AND SWORN to before me this ________th day of ___________, 2023 at

the Cagayan de Oro City. Affiant exhibited to me his valid proof of identification as described
above.