Republic of the Philippines)

Province of__________________) S.S.

City/Municipality of________)
x---------------------------------------/

AFFIDAVIT OF LOSS

I, JUAN DELA CRUZ Filipino, of legal age,(single / married /

widow),and a resident of_____________, Philippines, after being duly sworn
in accordance with law, depose and state:

That I am the registered owner of a certain motor vehicle, which is more

particularly described as follows:

Make:_____________
Series:_____________
Type of Body:_________
Motor No.____________
Chassis No.___________
Yr. Model_____________
Color_____________
Plate No.____________

That as a registered owner, I was issued a

Certificate of Registration (C.R.) and an Original Receipt (O.R.) for my
registration for the year_______by the Land Transportation Office (LTO)
of_____________City, Philippines;

That when I was about to register the said motor vehicle for year
2017, I could no longer find said Certificate of Registration and Official
Receipt of the said motor vehicle.

That despite diligent search and efforts to locate the said

documents, I could no longer find the same such that I believe that they
are now lost beyond recovery.
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 new Certificate of Registration and Original Receipt, in
lieu of the ones that were lost.

IN WITNESS WHEREOF, I have hereunto set my hand this_____ in

the City of___________, Philippines.

JUAN DELA CRUZ

Affiant
 JURAT

SUBSCRIBED AND SWORN TO BEFORE ME this ___ day of __________,

2017, Affiant personally presented to me his ___________ ID as valid and
competent proof of his identity.

Doc. No. _____:

Page No. _____;
Book No. _____:
Series of 2017.