LEGAL FORM: Affidavit of Loss

REPUBLIC OF THE PHILIPPINES]                                                                                                                  CITY OF MANILA  ] S.S.

AFFIDAVIT OF LOSS

            I, Juan Dela Cruz, of legal age, Filipino, and resident of Barangay 543, Sampaloc, Manila, after having been duly sworn to in accordance with law, hereby depose and state:

1.      I am the registered owner of a motor vehicle described below as follows, to wit:

MV File No. 102000000012345	Year Model: 2019
Make: Toyota	Type of Body: SUV
Engine No.: ABC1234	Chassis No.: ABCDE1234FGHIJ
Plate No. ABC 123	Fuel: Diesel

3.  As proof of ownership of the above described vehicle, I was issued by the Land Transportation Office (LTO) a Certificate of Registration and Official Receipt (OR) as proof of payment for the aforementioned vehicle;

4.    That on December 16, 2018, a fire destroyed our house located at Barangay 543, Sampaloc, Manila;

5.      Due to the said fire, pertinent documents and other papers were destroyed including the Original Certificate of Registration and Official Receipt;

6.  For all intents and purposes, the said original LTO Official receipt and Certificate of Registration is already lost beyond recovery;

7.    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;

8.      That the said documents were not confiscated by any government authorities in violation of RA 4136 and other related laws;

9.   That I shall assume any responsibility or liability if in any event I will use these documents for whatever illicit transactions;

10.  That I am executing this affidavit to attest to the veracity of my statements and to support the same in its request for duplicate copies of the lost OR/CR at the Land Transportation Office (LTO) where it has hand over the subject.

            IN WITNESS WHEREOF, I have hereunto set my hand this October 25, 2019 at City of Manila.

JUAN DELA CRUZ

Affiant

SUBSCRIBED AND SWORN to before me this 25^th day of October 2019 at City of Cagayan de Oro, Philippines, affiant exhibited to me his Driver's License No. K02-12345678-2 issued by Land Transportation, Manila.

Doc. No._________;

Page No. ________;

Book No. ________;

Series of 2019.