REPUBLIC OF THE PHILIPPINES)

CITY OF BAGUIO ) S.S.

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

AFFIDAVIT OF LOSS OR/CR

I, MAYO D. BANGCO-OG, of legal age and a resident of JC 260 Central Pico, La Trinidad,
Benguet, after having been duly sworn to in accordance with law, depose and state THAT:

I am the buyer of the motorcycle registered in the name of Aringay Slashers which is particularly
described as follows:

MAKE & TYPE : HONDA WAVE

COLOR : BLUE/ BLACK
CHASSIS NUMBER : _______________
PLATE NUMBER : _______________

That as proof of ownership of the above-described vehicle I was issued an original Certificate of
Registration(CR) and Official Receipt (OR) by the Land Transportation Office, Baguio City District;
Howerever, the said documents while in my possession were misplaced and could no longer be located
inspite of diligent efforts to locate them;

I lost no time in diligently trying to locate the said CERTIFICATE OF REGISTRATION AND
OFFICIAL RECEIPT but all efforts exerted proved futile and no to avail, and that the same is
considered lost and beyond recovery;

The said lost Certificate of Registration and Official Receipt was not lent to another person or entity
nor confiscated by any other law enforcement agency;

I blind myself to surrender the said Certificate of Registration together with the Official Receipt to
the district office that issued the same;

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

Purpose of this affidavit of loss is to secure Duplicate Certificate of Registration and Official Receipt
of the said motorcycle vehicle;

I am executing this affidavit for the aforesaid purpose/s as well as for attesting to the truth of the
statements herein declared, subject to the rules on perjury.

IN WITNESS WHEREOF, I have hereunto set my hand this _______________________, in

the City of Baguio, Philippines.
 (Affiant)

SUBSCRIBED AND SWORN TO BEFORE ME this ___________________________ in

Baguio City, Philippines, by the above-named person, personally known and identified by me to be the
same person who freely and voluntarily executed the foregoing affidavit.