REPUBLIC OF THE PHILIPPINES)

CITY OF MANILA) S.S.

AFFIDAVIT OF LOSS
I, name, of legal age, Filipino, single/married and a resident of address, after having been
duly sworn to in accordance with law, depose and state THAT:
1.

I am the registered owner of a certain motor vehicle, which is more particularly

described as follows:
Make:
Series:
Body type: Wagon
Engine no.:
Chassis no.:

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.

That the Official Receipt while in possession of an agent was misplaced and could no
longer be located in spite of diligent efforts to locate it;

4.

Said document was neither transferred to other persons/entity/financial institutions for

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

5.

Said document was not confiscated by any government authorities for violation of R.A.
4136 and other related laws;

6.

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

my request for issuance of new Official Receipt, in lieu of the one that was lost.
IN WITNESS WHEREOF, I have hereunto set my hand this August 30, 2016 at

Manila City, Metro Manila, Philippines.

____________________
Affiant

SUBCRIBED

AND

SWORN

TO before

me

this ___________________ in

_________________, Philippines, affiant exhibiting to me his/her competent evidence of

identity

by

way

of

on __________________.
Doc. No. _____;
Page No. _____;
Book No. _____;
Series of 20__.

__________________

issued

at

______________