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REPUBLIC OF THE PHILIPPINES )

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
________________________.

Doc. No. _____;


Page No. _____;
Book No. _____;
Series of ______.

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