AFFIDAVIT OF LOSS

REPUBLIC OF THE PHILIPPINES)

____________________________) SS. :

I, (Name of Affiant)., Filipino, of legal age, residing at (Address of Affiant), after

having been sworn in accordance with law hereby depose and state: THAT –

I am the true and lawful owner of a certain motor vehicle which is more particularly
described as follows:

MAKE : MOTOR NO. :

SERIES : SERIAL/CHASSIS NO. :
TYPE OF BODY : PLATE NO. :
YEAR MODEL : FILE NO. :

(Change the declaration below to the actual circumstances)

Sometime in June of this year, I was looking for the original Certificate of Registration of my car
but to my surprise, said Owner’s original Copy could not be found;

I took pains to look for said Certificate of Registration, to no avail;

I am executing this affidavit to attest to the truth of the foregoing and to request from the Land
Transportation Office of ____________, a copy of said Certificate of Registration.

IN WITNESS WHEREOF, I have hereunto set my hand this _____ day of _________. 2019 at
_____________________.

(Name Over Signature of Affiant)

SUBSCRIBED AND SWORN TO before me, a notary public in and for __________________,
this ____ day of ____________ 2019. The affiant whom I identified through the following competent
evidence of identity: (ID type and number), valid from (date) to (date) issued by (issuing authority),
personally signed the foregoing instrument before me and avowed under penalty of law to the whole
truth of the contents of said instrument.

NOTARY PUBLIC
Until December 31, 2019

Doc. No. : __________;

Page No. : __________;
Book No. : __________;
Series of 20 _____.