CITYT OF BACOLOD ) x-----------------------------x
AFFIDAVIT OF LOSS
I, ______________________, of legal age, Filipino, married and a
resident of _____________________________, after having been duly sworn to in accordance with law, hereby depose and say that:
1. I am the registered owner of a motor vehicle which is
particularly described as follows:
Make & Type: HONDA XRM
Motor No.: XRM110ME-7146634 Chassis No.: XRM1205Z-146634 Plate No.: IG3351 MV File No.: 0604-00000120020 Year Model/Color: 2006/Yellow
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. On _____________________________, a big fire broke out in our
Barangay, which destroyed all the houses including my house. All important documents together with the OR/CR of my motor vehicle were also destroyed during the said fire;
4. I am executing this affidavit to attest to the veracity of my
statements and to support my request for the issuance of new copies of the lost OR/CR with the Land Transportation Office.
IN WITNESS WHEREOF, I have hereunto set my hand this
__________________, in the __________________.
_______________________________ Affiant
SUBSCRIBED AND SWORN to before me in the _______________,
this January 18, 2014. Affiant exhibiting to me his ________________________.