REPUBLIC OF THE PHILIPPINES )

LA TRINIDAD, BENGUET…………)s.s.

AFFIDAVIT OF LOSS WITH UNDERTAKING

I, NAME, of legal age, single/married, Filipino Citizen and a resident of Guinaoang,
Mankayan, Benguet, Philippines, after being sworn to in accordance with law do hereby
depose and state that:

1. I am the vendee of a Motor Vehicle per a Deed of Sale docketed as Doc. No.:
24; Page No.: 05; Book No.: III; Series of 2019 of the Notarial Registry of the
undersigned Notary Public. Said motor vehicle is more particularly described as
follows:

Make/Series: Mitsubishi Delica Year Model: 2002

Motor no.: 4D56-DM0472 MV File No.: 1312-00000247570
Chassis no.: P35W-0106384 Plate no.: XGC115

2. The registered owner of the above-described motor vehicle, was issued a

Certificate of Registration (CR) by the Land Transportation Office upon
registration thereof and the same CR was surrendered to me upon the execution
of the said deed of sale;

3. I kept the said Certificate of Registration inside a compartment of the above

described motor vehicle;

4. Recently, however, when I searched for the said Certificate of Registration as I

needed it at the time, I was surprised to find out that the subject document is
missing and nowhere to be found despite my diligent efforts to search for the
same, which made me conclude that said Certificate of Registration is forever
lost and beyond recovery;

5. I bind myself criminally, administratively or civilly liable to any claim that may
arise in the future. The LTO or its officers shall not be held liable for processing the
foregoing and I undertake to answer for any damages that the LTO or any of its
officer may incur in honoring the same;

6. I further undertake to be personally responsible for the said loss;

7. Finally, I am executing this affidavit to attest to the veracity of the foregoing

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

IN WITNESS WHEREOF, I have hereunto affixed my signature this 5th day of September
2019 in La Trinidad, Benguet, Philippines.

NAME OF AFFIANT
Affiant
Passport No. P4051689A

SUBSCRIBED AND SWORN TO BEFORE ME, this 5th day of September 2019 in La Trinidad,
Benguet, Philippines.

Doc. No.:
Page No.:
Book No.:
Series of 2019.