REPUBLIC OF THE PHILIPPINES ) PROVINCE OF DAVAODELNORTE —) sss ISLAND GARDEN CITY OF SAMAL ) AFFIDAVIT OF LOSS OR/CR 1 , of legal age, Filipino, single/married/widow/widower/separated and a resident of after having been duly sworn to pursuant law, depose an 1. That | am the registered owner of the motor vehicle described below as, to wit: Make & Type Motor Number Chassis Number PlateNumber = 2. That , as proof of ownership of the above described vehicle | was issued by the Land Transportation Office, Official Receipt (OR) as proof of payment and Certificate of Registration (CR); 3. That the said documents while in my possession were misplaced and could no longer be located inspite of exerting efforts of locating them; 4. That the said documents were not in the possession of any bank institutions or lending companies by reason of encumbrances or chattel mortgage of the subject motor vehicle; 5. That the said documents were not confiscated by any governments authorities in violation of R.A. 4136 and other related laws; 6. ‘That 1 shall assume responsibility or liability #f in any event | will use these documents for whatever ilicit transactions; 7. ‘That | am executing this affidavit to attest to the veracity of my statements and to support the same in its requests for duplicate copies of the lost MVRR/MVMRR/OR/CR at ‘the Land Transportation Office (LTO) where it has a hand over subject. 8. That I bind myself criminally, civilly and administratively liable and will assume full responsibility for any 3" party claim, and hereby hold the Land Transportation Office or any of its employees free from any liability arising from any claim for damages as a result of the approval of the registration of the motor vehicle and or issuance of replacement certificate or registration. IN WITNESS HEREOF, | have hereunto set my hand this in Babak, Island Garden City of Samal, Philippines. ‘Affiant Res. Cert. No. Issued at on. 2012 SUBSCRIBED AND SWORN to before me th in Babak, Istand Garden City of Samal, Philippines, affiant exhibited to me her residence certificate, number of which is clearly written as above indicat ed. MARDOCHEO S. CAMPOREDONDO.