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Republic of the Philippines )

City of Ormoc ) S.S.

AFFIDAVIT OF LOSS

I, JONATHAN Y. NOVAL, of legal age, Filipino, married and with


residence at Brgy. Don Carlos Revilla, Ormoc City, Leyte, after having been
sworn to oath in accordance with law, hereby depose and state that:

1. I am the registered owner of a motor vehicle which is particularly


described as follows:

Make & Type: Motorcycle without Side Car


Engine Number: LX150CEP61836
Chassis Number: MH4LX150CCKP09919
Plate Number: 3135HN
MV File No. : 083200001532921
Year Model: 2012
Color: Black

2. That as a registered owner, I was issued a Certificate of


Registration (C.R.) and an Original Receipt (O.R.) for my
registration for the year 2015 by the Land Transportation Office
of Ormoc City, Philippines;

3. That when I was about to register the said motor vehicle for the
year 2017, I could no longer find said Certificate of Registration
(C.R.) of the said motor vehicle;

4. The said document while in my possession was misplaced and


could no longer be located in spite of diligent efforts to locate
them;

5. Said document was neither transferred to other


persons/entity/financial institutions for any consideration nor
encumbered to guarantee financial obligations with any financial
institution;

6. Said document was not confiscated by any government


authorities for violation of R.A. 4136 and other related laws;

7. I shall assume responsibility or liability if in any event I will use


this document for whatever illicit transactions;

8. I am executing this affidavit to attest to the veracity of my


statements and to support my request for duplicate copies of the
lost Certificate of Registration (CR) with the Land Transportation
Office (LTO).
IN WITNESS WHEREOF, I have hereunto affixed my signature this __ day
of April 2017 at Ormoc City, Leyte.

JONATHAN Y. NOVAL
Affiant

Subscribed and sworn to before me this ___ day of April 2017 at Ormoc
City, Leyte. Affiant exhibiting to me his UMID Identification Card CRN-0111-
2859353-7.

Doc. No. _____;


Page No. _____;
Book No. _____;
Series of 2017.