Republic of the Philippines)

Province of Cagayan_) S.S.

City/Municipality of Tuguegarao)

x-----------------------x

AFFIDAVIT OF LOSS

I, CHRISTIAN MARK I VALENCIA, Filipino, of legal age, married , and a resident of Linao Norte,
Tuguegarao City, Cagayan, Philippines, after being duly sworn in accordance with law, depose and
state:

1. That I am the registered owner of a certain motor vehicle, which is more particularly
described as follows:

Make : NISSAN

Series : EXALT DS MT

Type of Body : SEDAN-4-DOOR

Motor No. : QG15-000625

Chassis No. : CDFALDFN16-A35696

Yr. Model : 2002

Color : YELLOW

Plate No. : BCT642

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 2017 by the Land Transportation Office of
Aparri, Cagayan, Philippines;

3. That when I was about to register the said motor vehicle for year 2018, I could no longer find
said Certificate of Registration and Official Receipt of the said motor vehicle;

4. That despite diligent search and efforts to locate the said documents, I could no longer find
the same such that I believe that they are now lost beyond recovery;

5. As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing and to
support my application for the issuance of new Certificate of Registration and Original
Receipt, in lieu of the ones that were lost.
 IN WITNESS WHEREOF, I have hereunto set my hand this 24th day of January 2018 in the City
of Tuguegarao, Cagayan, Philippines.

CHRISTIAN MARK I. VALENCIA

Affiant

SUBSCRIBED AND SWORN to before me, this 24TH day of January 2018, by the Affiant who is
personally known to me (or whom I have identified through competent evidence of identity) and who
exhibited his/her Community Tax Certificate No. 454654114 issued at Tuguegarao City, Cagayan on
January 15, 2018.

Notary Public

Doc. No. ______;

Page No. ______;

Book No.______;

Series of 20____.