Republic of the Philippines )

Camiling, Tarlac ) S.S.

AFFIDAVIT OF LOSS

I, KENNETH LAO, 25 years old, single, Filipino citizen and a resident of

Barangay Surgui 1st, Camiling, Tarlac, Philippines, after having been duly sworn
to in accordance with law, do hereby depose and state THAT:

1. Sometime in January 2017, I purchased a motorcycle from Ms. Divina

M. De Guzman. Upon payment, the original copies of the Certificate of
Registration (COR) and Official Receipt (OR) of the said motorcycle
were handed to me and were kept, together with my other personal
effects, in a drawer inside my room for safekeeping;

2. Lately, when I was organizing my personal effects, I discovered that the

COR and OR of the said motorcycle were missing;

3. I immediately searched the other possible drawers and cabinets inside

my room where the said document might have been transferred but I
found nothing. I also asked the members of my household if they have
seen the said document but they all answered in the negative.

4. Diligent efforts exerted to locate the COR and OR of the said motorcycle
turned futile; hence, I now consider them as lost and beyond recovery;

5. The said COR and OR were never confiscated by any authority,

pledged or used as a security to any transaction;

6. I am executing this Affidavit to attest to the truth of the foregoing

statements and for all legal intents and purposes it may serve.

IN WITNESS WHEREOF, I have hereunto affixed my signature this 11th

day of July, 2017 at Camiling, Tarlac, Philippines.

KENNETH LAO
Affiant

SUBSCRIBED AND SWORN to before me on the date and place

indicated above. Affiant presented before me his PWD ID Card with ID No. 03-
6903-021048 issued by the Municipal Social Welfare and Development (MSWD),
Camiling, Tarlac on March 21, 2016.

Doc. No.:_______;
Page No.:______;
Book No.:______;
Series of 2017.