Republic of the Philippines )

LIPA CITY, BATANGAS ) S.S

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AFIDAVIT OF LOSS
I, ANITA OLAN, Filipino citizen, of legal age, married and a resident of Brgy.
Inosluban, Lipa City, Batangas, after having been duly sworn in accordance
with law, hereby depose and say:

1. That I am the registered owner of a certain motor vehicle described as

follows:
Make : CAR
Body Type : MAZDA
Motor/Engine No. : lf844242
Chassis No. : pe3bvsw151zh00643
Certificate of Reg. No. : ____________________
Plate No. : AOL-531
MV File No. : 1380-333425

2. That, unfortunately the ORIGINAL CERTIFICATE OF REGISTRATION of the

said motor vehicle was lost in my possession as I misplaced the same;

3. That, despite diligent efforts to locate the aforesaid original Certificate

of Registration, all my efforts proved futile;

4. That, I am executing this affidavit to attest the truth of all the foregoing
facts and to request the Land Transportation Office for the replacement of the
afore-stated Certificate of Registration of my motor vehicle and for whatever
legal purpose this may deem worth.

IN WITNESS WHEREOF, I have hereunto affixed my signature this 30th day of

June 2015 in Lipa City, Batangas.

ANITA OLAN
Affiant
ID No. ________________

SUBSCRIBED AND SWORN before me this 30th day of June 2015 at Lipa City,
Batangas, Philippines. Affiant exhibited to me her Government issued ID
abovementioned as competent evidence of her identity bearing her
photograph and signature in accordance with the 2004 Rules of Notarial
Practice.

Doc. No._____;
Page No._____;
Book No._____;
Series of 2015.