Republic of The Philippines) City of Bacolod) S.S. X - X
Republic of The Philippines) City of Bacolod) S.S. X - X
REPUBLIC OF THE PHILIPPINES )
PROVINCE OF NEGROS OCC ) S S
CITY OF BACOLOD )
AFFIDAVIT OF LOSS OR/CR
That I am one of the legal heir of the late __________________the registered owner of the
motor vehicle described below as, to wit:
Make & Type :
Motor Number :
Chassis Number :
Plate Number :
That , as proof of ownership of the above described vehicle the late
______________________________________ was issued by the LandTransportation Office,
Official Receipt (OR) as proof of payment and Certificate of Registration (CR);
That the said documents while in her/his possession and after his/her death the said OR/CR were
misplaced and could no longer be located inspite of exerting efforts of locating them;
That the said documents were not in the possession of any bank institutions orlending companies by
reason of encumbrances or chattel mortgage of the subject motorvehicle;
That the said documents were not confiscated by any governments authorities inviolation of R.A. 4136
and other related laws;
That I shall assume responsibility or liability if in any event I will use thesedocuments for
whatever illicit transactions;
That I am executing this affidavit to attest to the veracity of my statements and tosupport the same in its
requests for duplicate copies of the lost MVRR/MVMRR/OR/CR atthe Land Transportation Office (LTO)
where it has a hand over subject..
That I bind myself criminally, civilly and administratively liable and will assume fullresponsibility for
any 3rd party claim, and hereby hold the Land Transportation Office or anyof its employees
free from any liability arising from any claim for damages as a result of theapproval of
the registration of the motor vehicle and or issuance of replacement
certificateor registration.
IN WITNESS HEREOF, I have hereunto set my hand this _____________ in Bacolod
City , Philippines.
_______________________
Govt Issued ID No.
SUBSCRIBED AND SWORN to before me this _______________ in City of Bacolod , Philippines,
affiant exhibited to me her residence certificate, number and government issued ID of
which is clearly written as above indicated.
PublicDoc. No. _______;
Page No. _______;
Book No. _______;
Series of 2012.