Republic of the Philippines )

City of Cagayan de Oro ) S.S

AFFIDAVIT OF LOSS

I, RICHARD R. TAN, of legal age, Filipino, married, and a resident of 111-

113 Gomez St., Cagayan de Oro City, after having been duly sworn to in
accordance with law, depose and state THAT:

1. I am the registered owner of a motor vehicle which is particularly

described as follows:

Make & Type : Mitsubishi Montero SPT GLS

Engine Number : 4D56UCDG3526
Chassis Number : MMBGYKG40CF017769
Plate Number : KGK 408
MV File No. : 1036-00000179139
Year Model/Color : 2012 Brown

2. As proof of ownership of the above-described vehicle I was issued by

the Land Transportation Office, Official Receipt (OR) and Certificate of
Registration (CR);

3. However, my copy of the Official Receipt (OR) while in my possession

was misplaced and could no longer be located in spite of diligent efforts
to locate them;

4. Said document was neither transferred to other

persons/entity/financial institutions for any consideration nor
encumbered to guarantee financial obligations with any financial
institution;

5. Said document was not confiscated by any government authorities for

violation of R.A. 4136 and other related laws;

6. I shall assume responsibility or liability if in any event I will use this

document for whatever illicit transactions;

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

and to support my request for duplicate copies of the lost Official Receipt
(OR) with the Land Transportation Office (LTO).

IN WITNESS WHEREOF, I have hereunto set my hand this

___________________ in Cagayan de Oro City, Philippines.

RICHARD R. TAN
Affiant
SSS ID No. _____________
 SUBCRIBED AND SWORN TO before me this ___________________ in
_________________, Philippines, affiant exhibiting to me his competent evidence
of identity by way of __________________ issued at ______________ on
__________________.

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 2020.