REPUBLIC OF THE PHILIPPINES)

CITY OF ROXAS . . . . . . . . . . . . . .) S.S.

AFFIDAVIT OF LOSS WITH UNDERTAKING

I, JOHN JOHNof legal age, Filipino, married and a resident of Brgy. Batuan,
Pototan, Iloilo, Philippines, under oath, depose and state:

1. That, I am the owner of a certain motor vehicle as evidenced by a

Deed of Absolute Sale, copy of which is herein attached and made
an integral part hereof, said motor vehicle being more particularly
described as follows:

MAKE HONDA
TYPE MOTORCYCLE
PLATE NO. XXX
MOTOR NO. XXX
CHASSIS NO. XXX
CR NO. XXX

2. That, as an owner, I hold the owner’s copy of the Certificate of

Registration of the aforesaid motor vehicle, although its registration
is still under the name of the VENDOR, XXX, as I was not able to
transfer the same in my name yet;

3. That, I kept the said Certificate of Registration in my wallet;

4. That, sometime on February 14, 2019, when I checked my

Certificate of Registration (CR) and Official Receipt (OR) in my
wallet where I kept it, I discovered that it was already missing and
in spite of diligent efforts to find the same, I cannot anymore locate
it up to the present and I now believe that it is already lost and
beyond recovery;

5. That, for purposes of securing a duplicate Certificate of

Registration, I hereby undertake that I did not mortgage to any
person or entity the said motor vehicle;

6. That, by this undertaking, I hereby assume full responsibility

against claims of third persons involving the said motor vehicle, and
that I will hold the Land Transportation Office absolutely free and
harmless from any and all liabilities connected to and/or arising
therefrom;

7. That, I execute this affidavit to attest to the truthfulness of the

foregoing facts and support my request for a re-issuance of a new
owner’s duplicate copy of the Certificate of Registration for the
above-described motor vehicle.
 IN WITNESS WHEREOF, I have hereunto affixed my signature this
___________________ at the City of Roxas, Capiz, Philippines.

JOHN JOHN
Affiant

SUBSCRIBED AND SWORN TO before me, a Notary Public commissioned in

and for the City of Roxas, Province of Capiz, Philippines, this _________________ by
the affiant who is personally known to me and who appeared and signed the
foregoing AFFIDAVIT OF LOSS WITH UNDERTAKING in my presence within my
jurisdiction, and who avowed to the truth of its contents under the penalty of law.

Doc No.______;
Page No._____;
Book No._____;
Series of 2019.