REPUBLIC OF THE PHILIPPINES)

CITY OF TARLAC ) S.S.

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

AFFIDAVIT OF LOSS OR/CR

I, ANGELO A. SALUNGA, of legal age, Filipino, (single/married/widow) and a

resident of 5096 Jasmin St. Pulungbulu, Angeles City, Pampanga, after having been duly
sworn to in accordance with law, depose and state THAT:

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

Make & Type: YAMAHA

Motor Number: 40C-074792
Chassis Number: PA040C000C0116775
Plate Number: 7474QW
MV File No. : 1396-00000074923
Year Model/Color: 2012
OR No.: 000201224052604

2. As proof of ownership of the above-described vehicle I was issued by the Land

Transportation Office, Official Receipt (OR) and Certificate of Registration (CR);

3. The said documents while in my possession were misplaced and could no longer be
located in spite of diligent efforts to locate them;

4. Said documents were neither transferred to other persons/entity/financial institutions

for any consideration nor encumbered to guarantee financial obligations with any
financial institution;

5. Said documents were not confiscated by any government authorities for violation of
R.A. 4136 and other related laws;

6. I shall assume responsibility or liability if in any event I will use these documents for
whatever illicit transactions;

7. I am executing this affidavit to attest to the veracity of my statements and to support

my request for duplicate copies of the lost MVRR/MVMRR/OR/CR with the Land
Transportation Office (LTO).

IN WITNESS WHEREOF, I have hereunto set my hand

this ___________________ in the City of Tarlac, Philippines.

ANGELO A. SALUNGA
Affiant

SUBCRIBED AND SWORN TO before me this ___________________ in the City

of Tarlac, Philippines, affiant exhibiting to me his/her competent evidence of identity by
way of __________________ issued at ______________ on __________________.

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 2018.