Republic of the Philippines )

Province of Isabela ) S.S

Municipality of Naguilian )
X-----------------------------------X

AFFIDAVIT OF LOSS

I, Marie Dee B. Belagan, of legal age, married, Filipino, and with residence address at
Magsaysay, Naguilian, Isabela, after having duly sworn to in accordance with the law, hereby
depose and state that:

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

2. That sometime in year 2022, the Official Receipt and Certificate of Registration of the
Motor Vehicle describe as follows were lost in my possession;

Make : CHEVROLET
Denomination : SPORTS UTILITY VEHICLE
Series/Model : TRAILBLAZER
Body type : SUV
Serial/Chassis No. : MMM156MH0DH635697
Serial/ Engine No. : A9LG131241011
Year Model : 2013

3. I am executing this Affidavit to document the lost of the original Official Receipt and
Certificate of Registration in order to submit this document to the Land Transportation
Office (LTO);

4. The original Certificate of Registration of the said motor vehicle while in my possession
was lost and misplaced and despite diligent efforts in order to locate, the same could no
longer be found.

5. As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing and to
support the application for the issuance of new Certificate of Registration in lieu of the
one that lost.

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

______, 2022, in the Municipality of Naguilian, Isabela.

Marie Dee B. Belagan

Affiant

SUBSCRIBED AND SWORN TO before me this ___________ day of __________,

2023 in the Municipality of Naguilian, Isabela, Philippines, affiant exhibiting
his/her_____________ ID No.____________.

Doc. No. __________;

Page. No.__________;
Book No. __________;
Series of. __________;