REPUBLIC OF THE PHILIPPINES)

CITY OF MAKATI
) S.S.
x----------------------------x

AFFIDAVIT OF LOSS OR/CR

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).
IN WITNESS WHEREOF, I have hereunto set my hand
this ___________________ in Makati City, Metro Manila, Philippines.
____________________
Affiant
SSS ID No. _____________
SUBCRIBED
AND
SWORN
TO before
me
this ___________________ in _________________, Philippines, affiant
exhibiting to me his/her competent evidence of identity by way of
__________________
issued
at
______________
on __________________.
Doc. No. _____;
Page No. _____;
Book No. _____;

Series of 2013.