REPUBLIC OF THE PHILIPPINES )

BANGUED, ABRA ) S.S

AFFIDAVIT OF LOSS
I, _____________________, of legal age, Filipino citizen, with residence
at_______________________, after having been duly sworn to in accordance with
law, do hereby depose and say:

1. That I am the holder of Certificate of Registration of Motor vehicle,

specifically _______________ with plate number ___________, with engine
number _______________, with chasis number ___________________ and
under the name of my wife _________________;

2. That due to inadvertence, said Certificate of Registration of such motorcycle

has been lost on _____________ at ______________, and in spite of all
efforts made by me with due diligence to locate the same, I have been unable
to find up to this time.

3. That being not able to locate, the Certificate of Registration is now presumed
lost forever.
4. As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
and to support my application for the issuance of a new Certificate of Registration, in
liue of the one that was lost.
IN WITNESS WHEREOF, I hereunto set my hand this ___________________
at Bangued, Abra, Philippines.

_________________________
Affiant
_____ No.
___________
Issued on __________
Issued at __________

SUBSCRIBED AND SWORN TO BEFORE me this ____________________

at Bangued, Abra, Philippines.

Doc. No. ____

Page No. ____
Book No. ____
Series of ____