City of Roxas )
AFFIDAVIT OF LOSS
I, Name, Filipino, of legal age, residing at No. 25, Walangdaan St., Roxas City, Capiz,
after having been sworn to 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:
IN WITNESS WHEREOF, I have hereunto set my hand this 15th day of April. 2017 at
Roxas City, Capiz, Philippines.
Name of Affiant
Notary Public