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Republic of the Philippines )

Baguio City ) SS.

AFFIDAVIT OF LOSS
I, ELBERT GABAYNE, of legal age, married, Filipino Citizen with
residence and postal address at Ampucao Itogon, Benguet, Philippines, after
having been duly sworn to in accordance with law do hereby, depose and say:

1. That I am an owner of MOTOR VEHICLE (JITNEY) and with


corresponding CERTIFICATE OF REGISTRATION No. 163362463,
Dated January 16, 2013 ;

2. That the original copy of the said CERTIFICATE OF REGISTRATION


was kept among other items filed in a cabinet in our house, however
after cleaning and renovating a portion of our house, when I need the
aforesaid CERTIFICATE OF REGISTRATION I could not find it. I and
my family members exerted diligent effort to locate the CERTIFICATE
OF REGISTRAION at our house but could no longer be found, hence,
considered forever lost;

3. That the said CERTIFICATE OF REGISTRATION was never given nor


pledged to anyone for any purpose whatsoever, nor was taken or
confiscated by the authorities for any violation of the law by the
Philippine Government; and

4. That I am executing this affidavit to attest to the veracity and


truthfulness of my foregoing statements and to request for the
issuance of a new CERTIFICATE OF REGISTRATION No. 163362463,
in lieu to the lost one and for all legal intents and purposes it may
serve.

IN WITNESS WHEREOF, I have hereunto set my hand this 5th day of


July, 2016, at Baguio City, Philippines.

ELBERT GABAYNE
AFFIANT

SUBSCRIBED AND SWORN TO before me this 5th day of July, 2016 at


Baguio City, Philippines. Affiant personally appeared before me and to be the
same person who executed this instrument freely and willingly.

MODESTO T. ANDONG
Notary Public
Commission No. 35-NC-16-R/Until: December 31, 2017
PTR No. 2426420/12-15-2015/Baguio City
IBP No. 0980937/12-04-2015/Baguio-Benguet Chapter
Roll No. 31289/5-15-81/Manila
MCLE COMPLIANCE No. V-0002709/July 3, 2014
No. 13-B, 2nd Floor Old Market Bldg.,
Magsaysay Ave., Baguio City, Philippines
Doc. No. 221;
Page No. 45;
Book No. XVIII;
Series of 2016.

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