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Affidavit of Loss of Certificate of Ownership Papers of Automobile

REPUBLIC OF THE PHILIPPINES )

CITY OF DUMAGUETE ) S.S

I, Ma Kura Tan, of legal age, single, residing at Brgy. Junob,

Dumaguete City, after being sworn to in accordance with law, depose
and say:

1. That I am the true owner of an automobile, described as

follows:

Make: Toyota
Model: Camry
Chassis Serial No: 5YJSA1DG9DFP14705
Plate No: LLB 777

2. That the said automobile had been duly registered in my name

in the Land Transportation Office in Dumaguete City, Negros
Oriental for the year 2010 to present.

3. That the certificate of registration and other pertinent papers

of ownership of said automobile were among those burned and
destroyed on the 26th of February 2018 when my house and all
my personal belongings were completely destroyed by fire;

4. That said papers are now beyond recovery.

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IN WITNESS WHEREOF, I have hereunto set my hand this 13th day

of March, 2019, in the City of Dumaguete, Negros Oriental,
Philippines.

___________________________
Affiant

JURAT

SUBSCRIBED and sworn to before me, this 13th day of March, 2019, in
the City of Dumaguete by Ma Kura Tan with Passport No. EB6684441

Atty. Nash Denver Baya

IBP NO. 854908, 1/02/12, Iloilo City
PTR NO. 3621460, 1/02/12, Iloilo City
Roll Attorney NO. 32747
MCLE Comp. No. IV-0004785, 3/2/12