Affidavit of Loss of Certificate of Ownership Papers of Automobile AFFIDAVIT REPUBLIC OF THE PHILIPPINES PROVINCE OF _________________ MUNICIPALITY OF _____________

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I, _______________________________________ , of legal age, single / married, residing at ______________________________________________ , after being sworn in accordance with law, depose and say: That I am the true owner of an automobile, described as follows, to wit: Make/Type : ___________ Motor No. : ___________ Chasis No. : ___________ Plate No. : ___________ Trade Name C.R. No. : __________ Current O.R. No.: __________ File No. : __________ Classification : __________ : ________________

That the said automobile had been duly registered in my name in the Motor Vehicle Office in ____________________ for the year (or years) _________ ; That the certificate of registration and other pertinent papers of ownership of said automobile were among those burned and destroyed / loss in an earthquake / robbed on _________________________; That I made all possible means to locate it in all possible places that I might have place it; That said papers are now beyond recovery. IN WITNESS WHEREOF, I have hereunto set my hand this _____day of _______________________ , 20 ____, in the Municipality of ___________, Province of _______________ , Philippines.

_______________________ (Signature of affiant) SUBCRIBED AND SWORN to before me in the Province of La Union, Municipality of Agoo, Philippines, this 7th day of July at 2007. Affiant having exhibited to me his Community Tax Certificate No. 777-3333 issued on January 11, 2007 at Agoo, La Union. Doc. No. 123 Page No. 69 Book No. VII Series of 2007 ATTY _________________________________ COMMISSION NO. _____________________ NOTARY PUBLIC for AGOO, LA UNION UNTIL DECEMBER 31, 2007 OFFICE: 9 Cases Blvd. Brgy Sta Barbara, Agoo La Union ROLL NO. 00001 IBP NO. 1234567 ; 01/07/07 ; LA UNION PTR NO 1234567 ; 01/07/07 ; LA UNION MCLE COMPLIANCE No. __________; July 7, 2007