REPUBLIC OF THE PHILIPPINES)

CITY OF DUMAGUETE ) S.S.

AFFIDAVIT OF LOSS

I, EDGARDO CULI, of legal age, Filipino, (single/married/widow) and a

resident of Lower Batinguel, Dumaguete City, after having been duly sworn
to in accordance with law, depose and state that:

1. I am the registered owner of a motor vehicle which is particularly described

as follows:

Make & Type : MCX RAINE S100

Motor Number : MCXRINS10063011737
Chassis Number : MCXRINS10063011737

2. As proof of ownership of the above-described vehicle I was issued by the

Land Transportation Office, Official Receipt (OR) and Certificate of
Registration (CR);

3. The said documents while in my possession were misplaced and could no

longer be located in spite of diligent efforts to locate them;

4. Said documents were neither transferred to other persons/entity/financial

institutions for any consideration nor encumbered to guarantee financial
obligations with any financial institution;

5. Said documents were not confiscated by any government authorities for

violation of R.A. 4136 and other related laws;

6. I shall assume responsibility or liability if in any event I will use these

documents for whatever illicit transactions;

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

to support my request for duplicate copies of the lost MVRR/MVMRR/OR/CR
with the Land Transportation Office (LTO)Dumaguete City, Philippines.
 IN WITNESS WHEREOF, I have hereunto set my hand
this ___________________ in Dumaguete City, Negros
Oriental, Philippines.

Edgardo R. Culi
Affiant

SUBCRIBED AND SWORN TO before me

this ___________________ in Dumaguete City, Philippines, affiant
exhibiting to me his/her competent evidence of identity by way of
__________________ issued at ______________
on __________________.

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 2018.