REPUBLIC OF THE PHILIPPINES)

CITY OF ) S.S.
x----------------------------x

AFFIDAVIT OF LOSS OR/CR

I, ___________________________, of legal age, with an office address at

____________________________________ 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 : MOTOR NO. :

SERIES : SERIAL/CHASSIS NO. :

TYPE OF BODY : PLATE NO. :

YEAR MODEL : FILE NO. :

2. As proof of ownership of the above-described vehicle I was issued by the Land

Transportation Office, an Official Receipt (OR) and Certificate of Registration (CR);

3. The said documents while in my possession were misplaced and could no longer be located
despite 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

________________, Metro Manila, Philippines.

_________________
AFFIANT

SUBSCRIBED 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 ______.