REPUBLIC OF THE PHILIPPINES)

CITY OF IRIGA CITY ) S.S.

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

AFFIDAVIT OF LOSS
OFFICIAL RECEIPT (OR) AND CERTIFICATE OF REGISTRATION
(CR)

I, ___________________, of legal age, Filipino, (single/married/widow) and a resident of

_______________________________, after having been duly sworn to in accordance with law, depose
and state THAT:

1. I am the registered owner of a motor vehicle which is particularly described as follows:

Make & Type : _______________

Motor Number : ________________
Chassis Number : ________________
Plate Number : ________________
MV File No. : ________________
Year Model/Color : ________________

2. As proof of ownership of the above-described vehicle I was issued by the Land Transportation Office,
Official Receipt (OR) and Certificate of Registration (CR);

3. The said documents while in my possession were misplaced and could no longer be located in spite of
diligent efforts to locate them;

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

5. Said documents were not confiscated by any government authorities for violation of R.A. 4136 and other
related laws;

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

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

IN WITNESS WHEREOF, I have hereunto set my hand this ___________________ in Iriga

City, Camarines Sur, Philippines.

____________________
Affiant
ID No. __________________

SUBCRIBED AND SWORN TO before me this _________________________ in

_________________, Philippines, affiant exhibiting to me his/her competent evidence of identity by way
of __________________ issued at ______________ on __________________.

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 2013.