REPUBLIC OF THE PHILIPPINES )

CITY OF SAN FERNANDO, PAMPANGA)

AFFIDAVIT OF LOSS

I, MARIO R. DIZON , Filipino, of legal age, married, and a resident of 44 - Lourdes, City of
San Fernando, Pampanga, after having been duly sworn to in accordance with law, hereby
depose and say;

1. That I am the registered owner of the motor vehicle described below as, to wit:

MAKE & TYPE: KAWASAKI/MOTORCYCLE

MV FILE NO. 0306-00000020347
ENGINE NO.: DUMBRD54181
CHASSIS NO.: MD2DDDUZZRWD34377
PLATE NO.: 4422RF
SERIES: CT100DU
DENOMINATION: MOTORCYCLE WITH SIDECAR

2. That, as proof of ownership of the above described vehicle I was issued by the
Land Transportation Office, Official Receipt (OR) as proof of payment and Certificate of
Registration (CR);

3. That the Official Receipt (OR) while in my possession was misplaced and could no
longer be located despite of exerting efforts of locating them;

4. That the said documents were not in the possession of any bank institutions or
lending companies by reason of encumbrances or chattel mortgage of the subject motor
vehicle;

5. That the said documents were not confiscated by any governments authorities in
violation of R.A. 4136 and other related laws;

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

7. That I am executing this affidavit to attest to the veracity of my statements and to

support the same in its requests for duplicate copies of the lost Official Receipt (OR) at the
Land Transportation Office (LTO) where it has a hand over subject.

IN WITNESS HEREOF, I have hereunto set my hand this June 14, 2019 in City of San
Fernando, Pampanga.
MARIO R. DIZON
Affiant

SUBSCRIBED AND SWORN before me this June 14, 2019 at City of San Fernando,
Pampanga by affiant, personally known to me, who is the same person who personally signed
before me the foregoing affidavit that he executed the same.

Doc. No. ;
Page No. ;
Book No. ;
Series of 2019.