AFFIDAVIT OF LOSS

REPUBLIC OF THE PHILIPPINES )

Province of Cagayan ) S.S.
City of Tuguegarao )

I, XXX, Filipino, of legal age, residing at XXX, after having been sworn in accordance
with law hereby depose and state:

That I am the true and lawful owner of a certain vehicle which is more particularly
described as follows:

MAKE : HONDA ENGINE NO. : XXX

SERIES : XXX SERIAL/CHASSIS NO. : XXX
TYPE OF BODY : TC PLATE NO. : XXX
YEAR MODEL : 2016 FILE NO. : XXX

That sometime in December of this year, I was looking for the original Certificate of
Registration and Official Receipt of my motor vehicle but to my surprise, said Owner’s original
Copy could not be found;

That I took pains to look for said Certificate of Registration and Official Receipt, but to no
avail;

That I am executing this affidavit to attest to the truth of the foregoing.

IN WITNESS WHEREOF, I have hereunto set my hand this _______________ at XXX.

XXX

SUBSCRIBED AND SWORN to before me, this __________________________, in XXX, with

affiant exhibiting his ID No. _______________________.
.