REPUBLIC OF THE PHILIPPINES)

CITY OF ORMOC ) S.S.

x---------------------------------------------x

AFFIDAVIT OF LOSS

I, ALBERT PATRICK DEEN, of legal age, Filipino, and a resident of Barangay Canadieng, Ormoc City, Leyte,
after having been duly sworn to in accordance with law, depose and state THAT:

1. I am the owner of a vehicle more particularly described as follows:

Make Suzuki
Body type Versa Van
Model 2005
Engine No. F6A66537
Chassis No. DE51V867764
M/V-File No. 0751-0000008824
Color White
Plate No YHX504

2. The above-cited was previously owned by DANILO C. DEEN, JR. As proof of ownership of the said
vehicle, DANILO C. DEEN, JR. was issued an Official Receipt (OR) and Certificate of Registration
(CR) by the Land Transportation Office (LTO);

3. Said vehicle was sold unto me by DANILO C. DEEN, JR. Thus, the same executed a Deed of Absolute
Sale to transfer ownership of said vehicle. However, I was not able to process the registration of the
vehicle. Hence, the registration of said vehicle was not transferred to my name;

4. Sometime in 2020, said OR and CR were safely kept inside my bag. However, I lost said bag while I
was travelling back home;

5. Hence, I immediately tried to locate said bag, but in spite of diligent efforts, I could no longer locate
the same such that I now believe that said bag where my OR and CR were kept is now lost beyond
recovery;

6. Said documents were neither transferred to other persons/entity/financial institutions for any
consideration nor encumbered to guarantee financial obligations with any financial institution;

7. Said document was not confiscated by any government authorities for violation of R.A. 4136 and
other related laws;

8. I shall assume responsibility or liability if in any event I will use these documents for whatever
illicit transactions;

9. I am executing this affidavit to attest to the veracity of my statements and to support my request for
duplicate copies of the lost OR and CR with the Land Transportation Office (LTO).

IN WITNESS WHEREOF, I have hereunto set my hand this ___________________ in Ormoc City,
Leyte, Philippines.

ALBERT PATRICK DEEN

Affiant
ID No.

SUBSCRIBED AND SWORN to me before this _________________________, affiant exhibited to me his identity
card stated above which serves as competent evidence of his identity.
Doc. No. _____;
Page No. _____;
Book No. _____;
Series of 2023.