REPUBLIC OF THE PHILIPPINES )

BUTUAN CITY ) S.S.

AFFIDAVIT OF LOSS

I, ARTHUR C. ACOPIADO, of legal age, Filipino and a

resident of B1 L3 Green Meadows Subd., Barra Opol, Misamis
Oriental Region 10, after having been duly sworn according to
law depose and state:

1. That I am the owner of one (1) unit Toyota Innova 2.5G DSL
more particularly described as follows;

Make/Type : Toyota
Engine No. : 2KD6799141
Chassis No. : KUN405048404
Plate No : KGE 128

2. That the original Official Receipt issued by the Land

Transportation Office (LTO) was misplaced or lost.

3. That I could no longer locate and/or find the said Official

Receipt (OR) despite my diligent efforts to locate the same.

4. That I attest to the truth of the foregoing facts.

FURTHER AFFIANT SAYETH NONE.

IN WITNESS WHEREOF, I have hereunto set my hand

this ___ day of August 2014 at Butuan City.

ARTHUR C. ACOPIADO
Affiant

SUBSCRIBED AND SWORN to before me this ___ day of

August 2014 affiant exhibiting his Drivers License No.
____________________.

Doc. No. ___;

Page No. ___;
Book No. ___;
Series of 2014.