LTO Form 92

Republic of the Philippines

Province of __________________________
OFFICE OF THE PROVINCIAL TREASURER
Koronadal City

(Pursuant ot Section 258 of LGC)

NAME OF DECLARED OWNER

ADDRESS

Dear Sir/Madam:

On the basis of the records of this office, the undersigned hereby certifies that the following described real
property/properties, is/are delinquent in the payment of real property taxes for the year/s and in the amount/s indicated,
hereunder:

Declared Owner
Tax Declaration No. Kind of Property
PIN Location
Lot No. Bill No.

Classification Area Market Value Assessment level Assessed Value

AGRICULTURAL

Tax Due Add: Interest Due Totals

(Computation is good until August 31, 2019)

WHEREFORE, this Warrant of Levy is hereby issued on the property/properties described above pursuant to
Section 256 of the Local Government Code of 1991 (R.A. 7160) for the Total Amount of Delinquency of
covering the tax years period from for all intents and purposes therein provided.

Issued this day of at South Cotabato Provincial Treasurer's Office, Koronadal City.

Provincial Treasurer

Received by:

Signature: Date:

Printed Name: Time:

(Property Owner/Administrator or Representative)

ACKNOWLEDGEMENT:

Republic of the Philippines )

City Of ___________________ )
Province of _______________)
X---------------------------------------X

SUBSCRIBE AND SWORN to before me this ________ day of ____________________, 2019 at ___________,
____________________, Philippines. The Provincial Treasurer exhibited his/her Residence Certificate No.
________________ issued on ____________________________ at________________________, Philippines.

Doc No.:
Page No.:
Book No.:
Series of 2019

CC:
PASSO
ROD
Property Owner
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