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Affidavit of Loss: (Change The Declaration Below To The Actual Circumstances)

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AFFIDAVIT OF LOSS

REPUBLIC OF THE PHILIPPINES)


_____________________________ ) S.S.


I, (Name of Afant)., Filipino, of legal age, residing at (Address of Afant), after having
been sworn 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 : MOTOR NO. :
SERIES : SERIAL/CHASSIS NO. :
TYPE OF BODY : PLATE NO. :
YEAR MODEL : FILE NO. :


(Change the declaration below to the actual circumstances)

That sometime in June of this year, I was looking for the original
Certifcate of Registration of my car but to my surprise, said Owners
original Copy could not found;

That I took pains to look for said Certifcate of Registration, but to
no avail;

That I am executing this afdavit to attest to the truth of the
foregoing and to request from the Land Transportation Ofce of Angeles
City, a copy of said Certifcate of Registration.

IN WITNESS WHEREOF, I have hereunto set my hand this _____ day of _______________.
20___ at _________________________.



(Name Over Signature
of Afant)


SUBSCRIBED AND SWORN to before me, this ____ day of ______________, 20___ in
___________________ City, with afant exhibiting his CTC No. _______________ ,
Issued on ______________________ at _________________________.


NOTARY PUBLIC
Until December 31, 200___

Doc. No. : ________;
Page No. : ________;
Book No. : ________;
Series of 20___.

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