REPUBLIC OF THE PHILIPPINES)
) S.S.
I, (Name), of legal age, Filipino, married and a resident of (Address), after having been duly sworn to in accordance with law, depose and state:
That I am the true owner of _______________, described as follows to wit: (Description of property)
That the said automobile had been duly registered in my name in the Land Transportation Office in ___________ for the year (or years) ____________;
That the certificate of registration and other pertinent papers of ownership of said automobile were among those flooded and destroyed on ____________ when my house and all my personal belongings were completely destroyed by storm and flood;
That said papers are now beyond recovery.
IN WITNESS WHEREOF, I have hereunto set my hand this (Date) in (Place), Philippines.
(Name)Affiant
SUBCRIBED AND SWORN TO before me this (Date) in (Place), Philippines by (Name of Affiant) affiant exhibiting to me his Competent Evidence of Identity by way of Passport Identification(ID Number) issued on (Date) in(Place).
Notary Public
Doc. No. _____;
Page No. _____;
Book No. _____;
Series of 20__.