Republic of the Philippines )

City of Bislig ) s.s.

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

AFFIDAVIT OF DISCREPANCY AND

CORRECTION OF RECORD ENTRY
I, ABCDE FGHIJ KLMNO, Filipino, of legal age, married, and a resident of Purok 3,
Abraca Street, Bongo District, Mangagoy, Bislig City, after having been sworn to in accordance
with law, do hereby depose and state:
          
1. That I am the City General Services Officer and authorized representative of the
City General Services Office of the Local Government Unit of Tokyo City;

2. That the LGU-TOkyo City has purchased one (1) unit of SHOWO dumptruck on the
22nd of June 2017 from the supplier TKC Heavy Industries Corporation with the
following specifications:

MAKE  : HOWO
SERIES : ZZ3257M2944
DENOMINATION : TRUCK
COLOR : Red
YEAR MODEL : 2017
PLATE NO. : 0701-600000
FUEL : DIESEL
CR NO. : 2989000000
OR NO. : 1800000095
ENGINE NO. : WSSSSSS307038137
CHASSIS NO. : AAAAAAHN204945
NET WT. : 6,000 kg
GROSS WT. : 12,000 kg

3. That ABCDE FGHIJ KLMNO, President of the same supplier, has signed and
conformed with the Purchase Order No. 2016-09-683 (GF) issued by the City
General Services Office of the Local Government Unit of Bislig City. Attached
herewith is the machine copy of the Purchase Order marked as Annex “A”;

4. That the same supplier has processed the Comprehensive GSIS Insurance and
Land Transportation Office (LTO) Registration dated on the 17 th of January 2018 of
the same vehicle at the LTO Region 7 Field Office;

5. That the vehicle’s actual NET WEIGHT is 13,060 kg and NOT 6,000 kg, and its
actual GROSS VEHCICLE WEIGHT is 32,000 kg and NOT 12,000 kg, which were
erroneously entered as indicated in the LTO Certificate of Registration (C.R.). A
machine copy of the C.R. is hereto attached and marked as Annex “B”;

6. That there were no corrections made before because such discrepancies had just
been discovered;

7. That I am executing this affidavit in order to attest to the truth of the foregoing
circumstances and for the purposes of setting the records straight and declaring
the true and correct Net Weight is 13,060 kg and Gross Vehicle Weight is 32,000
kg of the aforesaid motor vehicle and for insurance claims purposes.

IN WITNESS WHEREOF, I have hereunto set my hand this 19 th day of July 2021 at
Bislig City, Philippines.

ABCDE FGHIJ KLMNO

Affiant

SUBSCRIBED AND SWORN to before me in the City of Bislig this 19 th day of July
2021, by affiant who has satisfactorily proven his identity by exhibiting to me his LTO Driver’s
License LO1-03-0000043 with expiry date on 18 th of July 2022, that he is the same person who
personally signed the foregoing affidavit before me and acknowledged that she executed the
same.

Doc. No.: _____;

Page No.: ____;
Book No.: ____;
Series of 2023.