REPUBLIC OF THE PHILIPPINES )

PROVINCE OF ISABELA ) ss.

MUNICIPALITY OF CABAGAN )

AFFIDAVIT OF LOSS

I, ANGELITO S. UY of legal age, single, Filipino and resident Ilagan, Isabela after
having been duly sworn to according to law hereby depose and state:

1. That I am the same person executing this affidavit;

2. That I have in my possession Official Receipt (OR) or Certificate of Registration (CR)

issued by LTO;

3. That I placed the said Official Receipt (OR) or Certificate of Registration (CR) inside my
cabinet for safe keeping;

4. That, on November 2019, after the Typhoon Ulyses, I noticed that my Official Receipt
(OR) or Certificate of Registration (CR) were missing;

5. That I exerted diligent efforts to locate the same, but proved futile;

6. That it was considered lost due to excusable negligence and mere inadvertence;

7. That I am executing this affidavit in order to attest the truthfulness of all the foregoing
statements and for all lawful intent and purposes it may serve.
IN WITNESS WHEREOF, I hereunto set my hand this ____________________ 2022
at Cabagan, Isabela.

THE LATE OF ALFREDO JOSE

Represented by:
ANGELITO S. UY
Affiant
Valid ID No. ________________
Issued by: _________________

SUBCRIBED AND SWORN TO BEFORE ME this _____________________ 2022

in Cabagan, Isabela, Philippines affiant exhibiting to me his valid id written below his name as
proof of his identity.

Doc No. _____ ;

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