AFFIDAVIT OF LOSS

Republic of the Philippines )

Province of ______ )
Municipality of ______ ) S.S.



I, ___________________, of legal age, single/married, residing at
____________, after being sworn in accordance with law, depose and say:

That I am the true owner of _______________, described as follows to wit:


(Description of property)


That the said automobile had been duly registered in my name in the Land
Transportation Office in ___________ for the year (or years) ____________;


That the certificate of registration and other pertinent papers of ownership of
said automobile were among those flooded and destroyed on ____________
when my house and all my personal belongings were completely destroyed by
storm and flood;


That said papers are now beyond recovery.


IN WITNESS WHEREOF, I have hereunto set my hand this ________ day of
________, 20__, in the Municipality of ____________, Province of
__________, Philippines.

____________________

(Signature of affiant)



SUBSCRIBED AND SWORN to me, in the Municipality of ________, this ____th
day of ______, 19 ____ by, _______ with Community Certificate No. _____
issued at _____ on ______, 2001.


____________________
Notary Public



Doc. No._____;
Page No._____;
Book No._____;
Series of 20____.