FORM NO. 7.

Affidavit of Loss of Certificate of

Ownership Papers of Automobile
AFFIDAVIT
REPUBLIC OF THE PHILIPPINES )
CITY OF______________________ ) S.S.
I___________________________, of legal age, single/ married,
residing at _____________________________________, after being
sworn to in accordance with law, depose and say:
1. That I am the true owner of automobile, described as follows:
Make:
Model:
Chassis Serial No.:
Plate No.:
2. That the said automobile had been duly registered in my name
in the Land Transportation Office in ________________ for the
year (or years)______________;
3. That the certificate of registration and other pertinent papers of
ownership of the said automobile were among those burned and
destroyed on ____________ when my house and all my
personal belongings were completely destroyed by fire;
4. That said papers are now beyond recovery.
IN WITNESS WHERE OF, I have hereunto set my hand this ____
day of ______, 2____, in the City of ________________,
Philippines.

_____________________
(Signature of Affiant)