REPUBLIC OF THE PHILIPPINES PROVINCE OF DAVAO DEL NORTE ISLAND GARDEN CITY OF SAMAL

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SSS

AFFIDAVIT OF LOSS OR/CR

I, __________________________________, of legal age, Filipino, single/married/widow/widower/separated and a resident of __________________ _______________________, after having been duly sworn to pursuant to law, depose and say: 1. That I am the registered owner of the motor vehicle described below as, to wit: Make & Type Motor Number Chassis Number Plate Number : : : :

2. That , as proof of ownership of the above described vehicle I was issued by the Land Transportation Office, Official Receipt (OR) as proof of payment and Certificate of Registration (CR); 3. That the said documents while in my possession were misplaced and could no longer be located inspite of exerting efforts of locating them; 4. That the said documents were not in the possession of any bank institutions or lending companies by reason of encumbrances or chattel mortgage of the subject motor vehicle; 5. That the said documents were not confiscated by any governments authorities in violation of R.A. 4136 and other related laws; 6. That I shall assume responsibility or liability if in any event I will use these documents for whatever illicit transactions; 7. That I am executing this affidavit to attest to the veracity of my statements and to support the same in its requests for duplicate copies of the lost MVRR/MVMRR/OR/CR at the Land Transportation Office (LTO) where it has a hand over subject. 8. That I bind myself criminally, civilly and administratively liable and will assume full responsibility for any 3rd party claim, and hereby hold the Land Transportation Office or any of its employees free from any liability arising from any claim for damages as a result of the approval of the registration of the motor vehicle and or issuance of replacement certificate or registration. IN WITNESS HEREOF, I have hereunto set my hand this _____________ in Babak, Island Garden City of Samal, Philippines. ________________________ Affiant Res. Cert. No. _____________ Issued at _________________ On _________________ 2012 SUBSCRIBED AND SWORN to before me this _______________ in Babak, Island Garden City of Samal, Philippines, affiant exhibited to me her residence certificate, number of which is clearly written as above indicated.

Doc. No. _______; Page No. _______; Book No. _______; Series of 2012.

MARDOCHEO S. CAMPOREDONDO Notary Public Until December 31, 2013 PTR No. 4186724 issued at Samal City on January 2, 2012 TIN 880-114-418-669