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FORM NO. 12.

AFFIDAVIT OF LOSS (CERTIFICATE OF


OWNERSHIP PAPERS OF AUTOMOBILE)

Affidavit of Loss of Certificate of Ownership Papers of


Automobile

REPUBLIC OF THE PHILIPPINES)

CITY OF BAGUIO ) S.S.

I, DUGONG O. DUTERTE, of legal age, married, residing at


#72, Marcos hi-way, Bakakeng Central, Baguio City, after
being sworn to in accordance with law, hereby say:

1. That I am the true owner of an automobile, described


as follows:

Make: Mitsubishi

Model: 2006

Chassis Serial No: FRRL89645-0987

Plate No.: AHN 654

2. That the described automobile had been duly registered


in my name in the Land Transportation Office in Baguio
City for the years 2006 to 2016;

3. That the certificate of registration and other pertinent


papers of ownership of said automobile were among
those burned and destroyed on December, 22, 2016
when my garage where the automobile was parked and

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all my personal belongings inside the garage were
completely destroyed by fire;

4. That the papers of the automobile are now under


recovery.

IN WITNESS WHEREOF, I have hereunto set my hand


this 20th day of January 2017, in the City of Baguio,
Philippines.

Dugong O. Duterte

(Signature
of Affiant)

SUBCRIBED and sworn to before me, this 20th day of


January 2017, in the City of Baguio, Philippines, by Dugong
O. Duterte exhibiting to me his Phil Health Card with no.
675438 issued on January 19, 2016 at Baguio City,
Philippines.

Doc. No. _12___;


ATTY. DENVER A.
Page No. _8___;
GAMLOSEN
Book No. __2__;
Series of NOTARY
2017 . NOTARY PUBLIC
Commission Serial No. 105
PUBLIC
Until December 31, 2017
ROLL NO. Roll No. 10987
P.T.R. No. 0007, 1/4/2017,
BAGUIO CITY,
Baguio.
PHILIPPINES
IBP No. 0003, 1/9/2017,
Baguio.
MCLE Compliance No. 1234

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