Republic of the Philippines)

Province of Northern Samar) S.S.

Municipality of Catarman)

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:

1. 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.____________

2. 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;

3. 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.

4. 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.
 
(JURAT)