REPUBLIC OF THE PHILIPPINES)

CITY OF DIPOLOG ) S.S.

x--------------------------------------x

AFFIDAVIT OF LOSS

I, ALBERTO BIRIO TA-ATA , of legal age, Filipino, married and a resident of Brgy.
Marapong, Osmeña, Zamboanga del Norte , after having been duly sworn to in
accordance with law, depose and state:

1. That I am a holder of an Original Copy of Certificate of Registration (C.R.) No.

218277080 of the 6 Wheel Vehicle describe below as, to wit;

MAKE/TYPE: Mitsubishi
ENGINE NO.: 4D35-E55010
PLATE NO.: RFS563
CHASSIS NO.:FE638F-522050

2. That the said documents while in my possession was misplaced and could no
longer be located inspite of exerting efforts of locating them;

3. That the said document was not in the possession of any bank institutions or
lending companies by reason of encumbrances or chattel mortgage of the
subject motor vehicle;

4. That the said document was not confiscated by any governments authorities in
violation of R.A. 4136 and other related laws;

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

6. That I am executing this affidavit to attest to the veracity of my statements and

to support the same in its requests for an original duplicate copy of the lost
C.R. at The Land Transportation Office (LTO) where it has a hand over subject.

IN WITNESS WHEREOF, I have hereunto set my hand

this ___________________ in Dipolog City, Philippines.

ALBERTO BIRIO TA-ATA

Affiant
Voter’s ID No.7214-0056A-B2269ABT10000
Issued at Osmeña, Zamboanga del Norte

SUBCRIBED AND SWORN TO before me this ___________________ in Dipolog

City, Philippines, affiant exhibiting to me his competent evidence of identity of which is
clearly written as above indicated.

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 2017.