Republic of the Philippines )

City of Davao ) S.S.

AFFIDAVIT OF LOSS

KNOW ALL MEN BY THESE PRESENTS:

I, AKMADSALIE M. TUTTUH of legal age, Filipino, single, with principal office

address at Barangay Madaum, Tagum City, Davao del Norte, after having been sworn in
accordance with law, hereby depose and states the following:

1. I am the possessor of the Certificate of Registration of one (1) unit of motor vehicle covered
by CR. No. 303046936 described as follows:

Make: MITSUBISHI
Series: CANTER
Engine No.: 4D35-D39707
Body Type: DROPSIDE W/ BOOM
Chassis No.: FE538EV-500567
Color: White

2. I have recently discovered the said document is irretrievably lost and can no longer be
found despite diligent efforts to locate the same;

3. I execute this affidavit to attest to the truth of the foregoing.

Signed on the date and the place indicated below.

AKMADSALIE M. TUTTUH
Affiant
ID No.:UMID CRN 0111-1236514-0

SUBSCRIBED and SWORN TO before me on the date and at the place indicated below.
The affiant exhibited to me his competent evidence of identity indicated above. Signed this
________________________ at _______________________, Philippines.

WITNESS MY HAND AND SEAL.

Doc. No.: ______.

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