REPUBLIC OF THE PHILIPPINES)

PROVINCE OF NUEVA VIZCAYA) S.S.

MUNICIPALITY OF BAYOMBONG)

AFFIDAVIT OF LOSS

I, REWIN RUDIO SERAPON, of legal age, married, Filipino citizen,

and presently residing at Brgy. Poblacion, Aritao, Nueva Vizcaya, after having
been duly sworn to an oath in accordance with law, do hereby depose and say
that:

1. I am a bonafide holder and possessor of ORIGINAL copy of the Certificate

of Registration (C.O.R) and an Official Receipt (O.R) of a car with plate
number PLH210, issued by Land Transportation Office, Bayombong,
Nueva Vizcaya;

2. Said Certificate of Registration and Official Receipt were always in my

possession however, sometime in June 17, 2007, I noticed that the Certificate
of Registration and Official Receipt were missing from the files where I
placed it and despite earnest efforts, I failed to find it;

3. Finding the futility of recovering the Original Copy of said C.O.R. and O.R,
it is hereby declared that the same are considered lost and beyond recovery;

4. I am executing this affidavit of loss to attest to the veracity of the foregoing

statements and to support my application for the issuance of another
Certificate of Registration and Official Receipt in lieu of the lost one.

IN WITNESS WHEREOF, I have hereunto set my hand on this affidavit

th
this 4 day of June 2017 at Bayombong, Nueva Vizcaya.

REWIN RUDIO SERAPON

Affiant

SUBSCRIBED AND SWORN TO before me this 4th day of June 2017 at

Bayombong, Nueva Vizcaya, affiant having exhibited to me his Postal Identification
Number 4029642 bearing his name and signature.