REPUBLIC OF THE PHILIPPINES)

) S.S.

AFFIDAVIT OF LOSS

I, ________________________, Filipino, of legal age and a resident of

_________________________________, after having been duly sworn to in accordance with
law, hereby depose and state that:

1. I am the authorized person of _______________ the registered owner of

___________ square meters parcel of land located in Municipality of
___________________, and covered by TCT No. ______________;

2. Sometime in ____________, lost thru mail the said original title, and
despite diligent efforts exerted to locate the same, I could not remember exactly where
I placed/left it, thus, considered it lost for all legal purposes;

3. The said TCT have not been given or surrendered to anyone as collateral
for any loan;

4. As such, I am executing this Affidavit of Loss to attest to the truth of the

foregoing and for whatever legal purpose this may serve.

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

__________in the City of ___________, Philippines.

______________________
Affiant

SUBSCRIBED AND SWORN to before me this ____day of ______, affiant

satisfactorily proven to me her identity through her ____________________, and that she
is the same person who personally signed before me the foregoing affidavit and
acknowledged that she executed the same.

Doc. No.____;
Page No. ___;
Book No. __;
Series of 2018.