Republic of the Philippines )

Province ofXXXXXXXXX)S.S
City of XXXXXXXX )
x---------------------------------------x

AFFIDAVIT OF LOSS

I, XXXXXXXXXXXXXX, of legal age, married, Filipino, and a resident

of XXXXXXXXXXXXXXXXXXXXXXXXX, do hereby depose and state that:

1. I am the registered owner of a motorcycle described as:

Make : Honda
Engine No. : KD12E7003449
MV File No. : 1101-00000602921
Chassis No. : MH1KD1279JK003492

2. That the Official Receipt and the Certificate of Registration of the

said motorcycle was in my possession, however these were lost and
could not be found;
3. I exerted all efforts to locate the said OR and CR but it rendered
futile;
4. Thus, I am executing this Affidavit to attest to the foregoing facts
and to apprise the authorities concerned.

IN WITNESS WHEREOF, I have hereunto set my hand this January

20, 2020 in the City of Mati, Davao Oriental.

XXXXXXXXXXXXXXXXXXX
Driver’s License No.: XXXXXX

SUBSCRIBED AND SWORN TO before me this ______________ in

the XXXXXXXXXXXXXXXXXXl, Philippines.