Republic of the Philippines

DEPARTMENT OF TRANSPORTATION
LAND TRANSPORTATION OFFICE
BRGY. TIZA ROXAS CITY, CAPIZ

Field Office: ROXAS CITY DISTRICT OFFICE, CAPIZ TIN: 000865491052

Office Code: 0636 Date: 05/24/2024 9:53 AM

OFFICIAL RECEIPT 0636-000000250556

RECEIVED FROM (Last Name, First Name Middle Name)
BURIO, JATHLEEN KAY VIGO
ADDRESS (No. Street, Barangay, Municipality, Zip Code, Province)
-, Poblacion Viii (Barangay Viii), Roxas City (Capital), 5800,
Capiz
TIN (Tax Identification Number) LTO Client ID / LTO BUSINESS ID
21-940620-0575289

PAYMENT DETAILS BREAKDOWN OF PAYMENT

Transaction: TX-DLS-20240523-809015 - Replacement Fee PHP 225.00
01
Application: REVISION OF RECORDS Revision of Records PHP 100.00
Fee
From: Name: BURIO, JATHLEEN
KAY, VIGO, Civil Status:
Single
To: Name: VIGO, JATHELEEN
KAY, BURIO, Civil Status:
Married
Classification: Driver's License
Lic. No: F04-24-001563

TOTAL AMOUNT PAID: PHP 325.00

AMOUNT IN WORDS: THREE HUNDRED TWENTY-FIVE PESOS

MODE OF PAYMENT: Cash

LOCATION: Roxas City District Office, Capiz
CASHIER: Maria Camia Agaton
POS MACHINE: ROXAS DO - CASHIER

This is a system generated Official Receipt. No Signatures needed.

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