REPUBLIC OF THE PHILIPPINES )

CITY OF ______________________ ) S.S.

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:

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 ________________, Philippines.

_____________________
Affiant

SUBSCRIBED AND SWORN TO before me this _________ in

_________________, Philippines, affiant exhibiting to me her
____________________________.

NOTARY PUBLIC
Doc. No. _____;
Page No. _____;
Book No. _____;
Series of _____.