Republic of the Philippines)

Ozamiz City ) S. S.

AFFIDAVIT OF LOSS

I, JULLY DY CO GUE, of legal age, married, and resides at Nacional,

Jimenez, Ozamiz City, Misamis Occidental , after being sworn in
accordance with law, hereby state and declare that:

1. That I am the holder of an original CERTIFICATE OF

REGISTRATION of a Sports Utility Vehicle Toyota RAV4 with
Plate No. USY 169 issued by Land Transportation Office at Ozamiz
City;

2. That sometime on October 27, 2022, at 8:00 pm while I was

commuting on my way home, my wallet got lost and could no longer
be found including the original CERTIFICATE OF REGISTRATION
of a Sports Utility Vehicle Toyota RAV4 with Plate No. USY 169;

3. That despite diligent efforts to locate the said original CERTIFICATE

OF REGISTRATION of a Sports Utility Vehicle Toyota RAV4 with
Plate No. USY 169 the same cannot be located and is now considered
lost for all intents and purposes;

4. That I am executing this affidavit to attest to the truth of the

foregoing facts and circumstances to support our application of a
new original CERTIFICATE OF REGISTRATION of a Sports
Utility Vehicle Toyota RAV4 with Plate No. USY 169 and for
whatever legal purposes it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this 7th day of

November 2022 at Ozamiz City, Philippines.

JULLY DY CO GUE
Affiant

SUBSCRIBED AND SWORN TO before me this 3rd day of

November 2022 at Ozamiz City, Philippines.. Affiant exhibiting to me his
own self as competent evidence of identity.

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 2022.