AFFIDAVIT OF LOSS

REPUBLIC OF THE PHILIPPINES)

_____________________________ ) S.S.

I, ROBERTO ICARO, Filipino, of legal age, residing at Tigkan, Naujan, Oriental Mindoro,
after having been sworn in accordance with law hereby depose and state:

That I am the true and lawful owner of a certain motor vehicle which is more particularly
described as follows:

MAKE : ISUZU MOTOR NO. : 4BC2-151713

SERIES : - SERIAL/CHASSIS NO. : MAR98-2977-C
TYPE OF BODY : JITNEY PLATE NO. : DTF456
YEAR MODEL : 1998 FILE NO. : 0472-00000092177
C.R. NO. : 7381425-2

That sometime in October of this year, I was looking for the original Certificate of Registration of
my vehicle but to my surprise, said Owner’s original Copy could not found;

That I took pains to look for said Certificate of Registration, but to no avail;

That I am executing this affidavit to attest to the truth of the foregoing and to request from the
Land Transportation Office of Angeles City, a copy of said Certificate of Registration.

IN WITNESS WHEREOF, I have hereunto set my hand this _____ day of _______________. 20___ at
_________________________.

FILL OUT

ROBERTO
ICARO

SUBSCRIBED AND SWORN to before me, this ____ day of ______________, 20___ in
___________________ City, with affiant exhibiting his CTC No. _______________ ,
Issued on ______________________ at _________________________.

NOTARY PUBLIC

Doc. No. : ________;

Page No. : ________;
Book No. : ________;
Series of 20_______