Republic 

of the Philippines
City of Puerto Princesa )S.S

AFFIDAVIT OF LOSS OR/CR 

  I, BALTAZAR A. TAN, of legal age, Filipino, (single/married/widow) and a resident of

Bgy. Sicsican, Purok Golden Valley, Puerto Princesa 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:

FRANCHISE 5766 CHASSIS #: KSW00193031

#:
MAKE: HONDA MOTOR #:
MODEL: 2016 PLATE #: 046007
BODY TYPE: TC MV FILE #: 0403-00000048955

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. That I was granted by the City Government of Puerto Princesa to operate as public transport
and was issued Motorized Tricycle Operator’s Permit (MTOP) under DPLG No.1069-2018
issued by the office of the City Mayor, Puerto Princesa City, License & Permits Division on 21th
of May 2018;

4. That sometime on February 2020, I discovered that the said franchise, OR/CR was probably
lost or misplaced; I could not find the same such that I now believe that it is now lost beyond recovery;

5. Said documents were neither transferred to other persons/entity/financial institutions for any

consideration nor encumbered to guarantee financial obligations with any financial institution;

6. Said documents were not confiscated by any government authorities for violation of R.A. 4136
and other related laws;

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

8. I am executing this affidavit to attest to the veracity of my statements and to support my request
for duplicate copies of the lost MVRR/MVMRR/OR/CR with the Land Transportation Office
(LTO).

         IN WITNESS WHEREOF, I have hereunto set my hand this 21th day of April
2023 in Puerto Princesa City, Palawan, Philippines.
          

BALTAZAR A. TAN
Affiant
LTO ID No.D11-01-044602

    SUBCRIBED AND SWORN TO before me this 21th day of April 2023 in Puerto

Princesa City, Palawan, Philippines, affiant exhibiting to me his valid proof of
identification.

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 2023.