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REPUBLIC OF THE PHILIPPINES)

QUEZON CITY ) SS.

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AFFIDAVIT OF LOSS

I, EDDIE P. CANCERAN, of legal age, Filipino, married and a resident of Poblacion I,


Bliss Site, Santa Maria, Isabela, after having been duly sworn to in accordance with law, depose
and state THAT:

1. That I am a holder of an OR/CR issued by the Land Transportation Office for my


motorcycle with plate number _____________;

2. That sometime on December 2018, I unintentionally misplaced the said OR/CR;

3. That the diligent effort to locate the same had proved futile;

4. That the said OR/CR was not confiscated by the authorities or used in violation of the
law;

5. That I am executing this Affidavit to attest to the truth of the foregoing facts and to use
the same for whatever legal purpose it may serve.

IN WITNESS WHEREOF, I have hereunto affixed my signature this 24th day of April
at Quezon City, Philippines.

EDDIE P. CANCERAN
(Signature of Affiant over Printed Name)

SUBSCRIBED AND SWORN TO before me, a notary public in and for Quezon City this
April 24, 2019. The affiant, whom I identified through the following competent evidence of
Identity, __________________, valid from _________________________ issued by
___________________________, personally signed the foregoing instrument before me and
avowed under penalty of law to the whole truth of the contents of said instrument.

Doc. No.:238
Page No.: 49
Book No. VII
Series of 2019