Republic of the Philippines)

City of Tagum )S.S.

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

AFFIDAVIT OF LOSS

I, KAMILO R. FERNANDO, of legal age, Filipino, married and a resident of

Purok Lemonsito, Mankilam, Tagum City, Davao del Norte, Philippines, after having
been duly sworn to in accordance with law, depose and state THAT:

1. I am the owner of one (1) unit Wingvan bearing plate no. RGR 397,
Official Receipt No. 765751792 and Certificate of Registration No.
10313938-5;

2. Recently, I discovered that the said Official Receipt and Certificate of

Registration was misplaced and got lost;

3. Efforts were exerted to locate said Official Receipt and Certificate of

Registration, but in spite of diligent search, it could not be found and the
same is now beyond recovery;

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 renewal of registration in
lieu of the lost one;

IN WITNESS WHEREOF, I have hereunto set my hand this 26th day of July,
2017 at Tagum City, Davao del Norte, Philippines.

KAMILO R. FERNANDO
Affiant

SUBCRIBED AND SWORN TO before me this 26th day of July, 2017 , at

Tagum City, Davao del Norte, Philippines, affiant exhibiting to me his competent
evidence of identity by way of_____________________.

Doc. No. 431;

Page No. 87;
Book No. CLXXVI;
Series of 2017.