REPUBLIC OF THE PHILIPPINES)

CITY OF ORMOC ) S.S.

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

AFFIDAVIT OF LOSS
I, JIMMY G. PATANAO, of legal age, single, Filipino citizen, and a resident of Barangay Lao, Ormoc City,
Leyte, Philippines, after having been duly sworn to in accordance with law, depose and state THAT:

1. I am the registered owner of a private motorcycle – without sidecar more particularly

described as follows:
Make KAWASAKI
Body type MOTORCYCLE
Denomination MOTORCYCLE WITHOUT SIDE CAR
Series CT150A
MV File No. 0801-00000337410
Engine No. PFZWKD56805
Chassis No. MD2A21BY4KWD51174
Year Model 2019
CR No. 3864955-1
OR No. 1883639063

2. As proof of ownership of the above-described vehicle, I was issued by the Land Transportation
Office (LTO) with an Official Receipt (OR) and Certificate of Registration (CR);

3. Sometime in December 2022, said OR was placed inside my pouch. However, when I was
heading back home from work, I realized that said pouch is lost. Hence, I immediately tried to
locate said pouch, but in spite of diligent efforts, I could no longer locate the same such that I
now believe that said OR is now lost beyond recovery;

4. Said OR was neither transferred to other persons/entity/financial institutions for any

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

5. Said OR 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 these documents 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 copy of the lost OR with the Land Transportation Office (LTO).

IN WITNESS WHEREOF, I have hereunto set my hand this ___________________ in Ormoc City,
Leyte, Philippines.

JIMMY G. PATANAO
Affiant
ID No. Driver’s License
No. H03-06-001525 (Expiry 2024/11/07)

SUBSCRIBED AND SWORN to me before this _________________________, affiant exhibited to me his

identity card stated above which serves as competent evidence of his identity.

Doc. No. _____;

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