Republic of the Philippines)

City of Cagayan de Oro…..) ss.

AFFIDAVIT OF LOSS

I, HELEN ANNIE WILLKOM QUIMPO, of legal age, Filipino, and a resident

of No. 46, Quimpo Coumpound, Concordio Diel Street, Ilaya, Carmen, Cagayan de Oro
City, Philippines, after having been duly sworn to in accordance with law do hereby
depose and say:

1. That I am a holder of an Official Receipt (O.R.) with receipt number 556089052

and a Certificate of Registration (C.R.) with certificate number 199760315 both
issued by the Land Transportation Office;

2. That I placed the said O.R. and C.R. inside the under-seat storage compartment
of my motorcycle. However, when I searched for it sometime in the month of
February 2019, I could no longer find them;

3. That I exerted efforts to locate the O.R. and C.R. but such efforts have been
proven futile as I could no longer find them and now I consider them now as lost
beyond recovery;

4. That I execute this affidavit attesting to the truth of the foregoing facts and for
whatever legal purpose that this may serve best.

IN WITNESS WHEREOF, I hereunto affix my signature this

______________________ at Cagayan de Oro City.

HELEN ANNIE WILLKOM QUIMPO

Affiant

SUBSCRIBED AND SWORN to before me, a notary public, in and for the City
of Cagayan de Oro City, this ____________________________ at Cagayan de Oro City,
Misamis Oriental, Philippines, by HELEN ANNIE WILLKOM QUIMPO affiant
appearing before me with her ________________________________ and presenting to
me a document entitled Affidavit of Loss, affiant known to me through her officially
issued identity card bearing her photograph and signature and who signed said document
in my presence and sworn as to said document that she understood the contents thereof
and that the same was her free and voluntary act.

I HEREBY CERTIFY that I have personally examined the affiant and am

satisfied that she has read and understood his affidavit the contents of which she has
personal knowledge.