REPUBLIC OF THE PHILIPPINES)

CITY OF MAKATI ) S.S.

x----------------------------x

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 ____ day of ___________ 20____ in ____________, _____________, Philippines.

___________________________________

Affiant

SSS ID No. _____________

SUBSCRIBED AND SWORN to before me, this ____ day of __________ 20____, in the City of __________________, by ___________________ with Passport No.________________ issued on __________________ at _____________.

Notary Public

Doc. No. ______;

Page No. ______;

Book No. ______;

Series of ______;