(Affidavit of Loss OR CR of Motor Vehicle)

Republic of the Philippines)

Province of________________) S.S.
City/Municipality of_____________)
x---------x

AFFIDAVIT OF LOSS

I,_____________, Filipino, of legal age,(single / married / widow),and a resident of_____________,

Philippines, after being duly sworn in accordance with law, depose and state:

That I am the registered owner of a certain motor vehicle, which is more particularly described as
follows:

Make:_____________
Series:_____________
Type of Body:_________
Motor No.____________
Chassis No.___________
Yr. Model_____________
Color_____________
Plate No.____________

That as a registered owner, I was issued a Certificate of Registration (C.R.) and an Original Receipt (O.R.)
for my registration for the year_______by the Land Transportation Office of_____________City,
Philippines;

That when I was about to register the said motor vehicle for year_________, I could no longer find said
Certificate of Registration and Official Receipt of the said motor vehicle.

That despite diligent search and efforts to locate the said documents, I could no longer find the same
such that I believe that they are now lost beyond recovery.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing and to support my
application for the issuance of new Certificate of Registration and Original Receipt, in lieu of the ones
that were lost.

IN WITNESS WHEREOF,I have hereunto set my hand this_____________in the City of___________,
Philippines.