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Republic of the Philippines)

City of Iloilo ) S.S.



I, ________________, of legal age, widow, Filipino and a resident of

__________________________________, after having been duly sworn under oath,
hereby depose and state that:

1. I am the registered owner of a parcel of land (Lot ______) covered by

Transfer Certificate of Title No. ____________,situated in
______________________ containing of an area of
_________________________ .



4. I certify and confirm that the parcel of land covered by Transfer Certificate
of Title No. ___________________ of the Registry of Deeds of Iloilo was never
mortgaged, sold, conveyed, disposed of, or encumbered, to any other person or
entity. I certify and confirm further that said document was neither confiscated nor
relinquished in favor of, any government entity agency, or authority;

4. I attest to the truth of the foregoing statements to the best of my own

personal knowledge and based on authentic documents or records. I am
executing this Affidavit of Loss to support my application for a new owner’s duplicate
copy of Transfer Certificate of Title No. ______________ as well as for all
lawful intents and purposes it may serve.

IN WITNESS WHEREOF, I have affixed my signature this _________________

at Iloilo City, Philippines.


SUBSCRIBED AND SWORN to before me this ___________ in the City of Iloilo,

Philippines, affiant known to me and was identified by me through competent evidence
of identity as defined by the 2004 Rules on Notarial Practice consisting of their I.D. No.