REPUBLIC OF THE PHILIPPINE )

PROVINCE OF SOUTH COTABATO) SS.

CITY OF KORONADAL )
x----------------------------------------------x

AFFIDAVIT OF LOSS
THAT I, JOHNNY H. BACELONIA, of legal age, Filipino, married and a
resident of Brgy. San Isidro, Koronadal City, South Cotabato, after having been duly
sworn to in accordance with the law, hereby depose and say:

1. That I am the registered owner of a certain tricycle, which is more particularly

described as follows, to wit:

Make-------------------- KAWASAKI
Body Type-------------- MC W/ SC
Engine No. ------------- DUMBUJ37516
Chassis No. ------------ MD2DDDUZZUWJ13268
Plate No. --------------- 4845MV
2. That recently, I discovered that I lost the original copy of the Official Receipt
(OR) and Certificate of Registration (CR) of the abovementioned tricycle, and
despite diligent effort to retrieve the same was in vain for up to this time they are
nowhere to be found and for all intents and purposes, they are deemed totally
LOST;

3. That I am executing this affidavit to attest to the truth of all the foregoing
statements for the purpose of securing another original copy of said Certificate of
Registration (CR) of the abovementioned tricycle.

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

Koronadal City, South Cotabato, Philippines.

JOHNNY H. BACELONIA
Affiant
PDL No. L05-97-030581

SUBSCRIBED AND SWORN to before me this _______________, at Koronadal

City, South Cotabato, Philippines.

Doc. No.___;
Page No.___;
Book No.___;
Series of 2021