REPUBLIC OF THE PHILIPPINES )

PROVINCE OF PAMPANGA ) S.S.

AFFIDAVIT OF LOSS

I, JOHN LESTER B. MIGUEL, of legal age, Filipino Citizen, with

residence at Purok 5 Baruya, Lubao, Pampanga after having been duly sworn to
in accordance with law, hereby depose and state:

1.) That I am holder of LTO Official Receipt issued by the LAND

TRANSPORTATION OFFICE;

2.) That on March 23 2021, I and my cousin went to Lubao Public

Market at Sta. Cruz Lubao, Pampanga, to purchase of our daily food
consumption and when I was about to pay the goods that we bought, I found out
that my wallet was missing and among those belongings that were missing is
my LTO Official Receipt and I diligently tried to search for it, but to no avail;

3.) That in all likelihood the said receipt was taken by a thief;

4.) That when I went home I tried to locate it but I failed to find the
same; and

5.) That this Affidavit is executed to attest to the truth of foregoing

facts and for the purpose of informing the government authorities concerned
relative the circumstances of loss of my LTO Official Receipt; and respectfully
request the LAND TRANSPORATION OFFICE for the issuance of duplicate
copy or a new one.

IN WITNESS WHEREOF, I have hereunto set my hand this 24 th day of

March, 2021 at Lubao, Pampanga.

JOHN LESTER B. MIGUEL

AFFIANT
PRC I.D. No. 0049002

SUBSCRIBED AND SWORN to before me on this 24th day of March,

2021 at Lubao, Pampanga. Affiant exhibited to me his Identification Document
stated below his name.

Doc No. ______

Page No. _____
Book No. _____
Series of 2021.