REPUBLIC OF THE PHILIPPINES )

Province of Capiz ) S.S.

City of Roxas )

AFFIDAVIT OF LOSS

I, Name, Filipino, of legal age, residing at No. 25, Walangdaan St., Roxas City, Capiz,
after having been sworn to in accordance with law hereby depose and state:

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

MAKE: Honda MOTOR NO.: 12345678

SERIES: XRM SERIAL/CHASSIS NO.: 98765432

YEAR MODEL: 2015 PLATE NO.: FFY 123

That sometime in March of this year, I was looking for the

original Certificate of Registration of the said motor vehicle but to my
surprise, said Owners Original Copy could not found;

That I took pains to look for said Certificate of Registration, but to no

avail;

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

and to request from the Land Transportation Office of Roxas City, Capiz, a
copy of said Certificate of Registration.

IN WITNESS WHEREOF, I have hereunto set my hand this 15th day of April. 2017 at
Roxas City, Capiz, Philippines.
 Name of Affiant

SUBSCRIBED and SWORN TO before me this 21st day of April 2017 at

_______________, Philippines, affiant exhibiting to me her SSS ID with ID No.
______________ issued by the Social Security System, as competent evidence of her
identity, and she personally acknowledged to me that the foregoing Petition is her free
and voluntary act and deed. Machine copy of this SSS ID is hereto attached.

Atty. Karmila D. Abogada

Notary Public

PTR No. 1234567, Iloilo City, 1/2/17

IBP OR No. 654321, Iloilo City, 1/2/17

Attorneys Roll No. 11122

MCLE Compliance Certificate No. IV-

0025415, Pasig City, 1/2/17

Doc No. _____;

Page No. _____;
Book No. _____;
Series of 20______.