REPUBLIC OF THE PHILIPPINES)

QUEZON CITY
) S.S.
x---------------------------------x
AFFIDAVIT OF LOSS VEHICLE CERTIFICATE OF REGISTRATION
I, _________________, of legal age, Filipino, married and a resident of #
_________________________________, after having been duly sworn to in
accordance with law, depose and state THAT:
1. I am the registered owner of a motor vehicle which is particularly described as
follows:
Make & Type : Honda Civic
Motor Number : _______________
Chassis Number : ______________
Plate Number : _______________
MV File No. : __________________
Year Model: 1999
2. As proof of ownership of the above-described vehicle I was issued by the Land
Transportation Office, Official Receipt (OR) No.920888485 when I had the said
vehicle registered last April 22, 2016;
3. Its corresponding CERTIFICATE OF REGISTRATION while in my possession were
misplaced and could no longer be located in spite of diligent efforts to locate them;
4. Said document were 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 duplicate copy of the lost CERTIFICATE OF REGISTRATION
with the Land Transportation Office (LTO).
IN WITNESS WHEREOF, I have hereunto set my hand this 18th of October
2016 in QUEZON CITY, Metro Manila, Philippines.

_______________
Affiant

SUBCRIBED AND SWORN TO before me this 18th of October 2016 in QUEZON

CITY, Philippines, affiant exhibiting to me his competent evidence of identity by way
of LTO Drivers License No. ______________ valid until _______________.
Doc. No. _631_;
Page No. __23_;
Book No. _ II__;
Series of 2016.