Republic of the Philippines )

City of Puerto Princesa )

AFFIDAVIT OF LOSS OR/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:

FRANCHISE CHASSIS #:
#:
MAKE: MOTOR #:
MODEL: PLATE #:
BODY TYPE: MV FILE #:

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 ____ day of

________ 2023 in Puerto Princesa City, Palawan, Philippines.

_____________________
Affiant

_____________________

SUBCRIBED AND SWORN TO before me this ____ day of ________ 2023 in Puerto
Princesa City, Palawan, Philippines, affiant exhibiting to me his valid proof of
identification.

Doc. No. _____; ATTY. JOEMAR P. CALUNA

Page No. _____; NOTARY PUBLIC
Book No. _____; UNTIL DECEMBER 31, 2023
Series of 2023. PURSUANT TO BAR MATTER NO. 3795
PTR. 1778716/02/22/2023
IBP NO. 230900/06/11/12
ROLL NO. 82822
NPL NO. 2022-05