AFFIDAVIT OF LOSS

REPUBLIC OF THE PHILIPPINES)

_____________________________ ) S.S.

I, (Name of Affiant)., Filipino, of legal age, residing at (Address of Affiant), after having
been sworn in accordance with law hereby depose and state:

That I am the true and lawful owner of a certain motor vehicle

which is more particularly described as follows:

MAKE : MOTOR NO. :

SERIES : SERIAL/CHASSIS NO. :
TYPE OF BODY : PLATE NO. :
YEAR MODEL : FILE NO. :

(Change the declaration below to the actual circumstances)

That sometime in June of this year, I was looking for the original
Certificate of Registration of my car but to my surprise, said Owner’s
original Copy could not found;

That I took pains to look for said Certificate of Registration, but to

no avail;

That I am executing this affidavit to attest to the truth of the

foregoing and to request from the Land Transportation Office of Angeles
City, a copy of said Certificate of Registration.

IN WITNESS WHEREOF, I have hereunto set my hand this _____ day of _______________.
200__ at _________________________.

(Name Over Signature

of Affiant)

SUBSCRIBED AND SWORN to before me, this ____ day of ______________, 200___ in
___________________ City, with affiant exhibiting his CTC No. _______________ ,
Issued on ______________________ at _________________________.

NOTARY PUBLIC
Until December 31, 200___

Doc. No. : ________;

Page No. : ________;
Book No. : ________;
Series of 200__.