Republic of the Philippines )

City of Ormoc ) S.S.

AFFIDAVIT OF LOSS

I, BENJAMIN O. MISTOLA SR., of legal age, Filipino and a resident of Purok 1,

Danao, Ormoc City, Leyte, Philippines, after having been duly sworn to in accordance with
law, depose and state:

1. That I am the registered owner of a one (1) unit HONDA TC HIRE which is
particularly described as follows;

MAKE/TYPE - HONDA TC HIRE

CHASSIS NO. - KB509156605
ENGINE NO. - KB509E156605
SERIES - TMX1559
C.R. NO. - 231614025
O.R. NO. - 1795938653

2. That as proof ownership of the above-described vehicle, I was in possession of

a Certificate of Registration and Official Receipt by the Land Transportation
Office, Ormoc City;

3. That the said item while in my possession was misplaced and could no longer
be located in spite of diligent efforts to locate;

4. That said item was neither transferred to other persons/entity/financial

institutions for any consideration nor encumbered to guarantee financial
obligations with any financial institution;

5. That said item was not confiscated by any government authorities for violation
of RA 4136 and other related laws;

6. That I shall assume responsibility or liability if in any event I will use these
items for whatever illicit transactions;

7. That as such, I execute this affidavit to attest to the foregoing facts and to
support the application for the issuance of a new one which were lost. 

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

_______, 2023 in Ormoc City, Philippines.

BENJAMIN O. MISTOLA SR.

Affiant
SSS No. 06-1453172-9

  SUBCRIBED AND SWORN TO before me this _ day of _______, 2023 in

Ormoc City, Leyte, Philippines.

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 2023.