REPUBLIC OF THE PHILIPPINES)

Province of Camarines Sur) S.S.

City of Naga)
x-----------------------x

AFFIDAVIT OF LOSS

I, FLORENTINO PERPETUO P. REQUINTA, Filipino, of legal age,

married, and a resident of La Purisima St., Goa, Camarines Sur, after being
duly sworn to in accordance with law, hereby depose and state:

1. That I am a donee of a parcel of land denominated as Lot 16, Plan Psu-

152508, L.R. Case No. N-838. LRC Record No. N-14395, located at
Barangay Matacla, Goa, Camarines Sur, with an area of 31,705 square
meters, more or less, more particularly described and covered by
Original Certificate of Title (OCT) No. RO-449(899) registered under the
name of my deceased mother Ester Pinto;

2. That the above-mentioned lot was donated by my parents, Florentino C.

Requinta and Ester Pinto, to me through an unregistered Deed of
Donation Inter Vivos duly executed on July 30, 1987 as duly notarized
before Gregorio P. Deleña (Municipal Trial Judge and Notary Public Ex-
Officio) with Doc. No: 96, Page No:21, Book No. 18 and series of 1987;

3. That the owner’s duplicate copy of the above-mentioned title was

formerly in the care and possession of my deceased mother Ester Pinto;

4. That sometime in the 1980s, my mother went to the Department of

Agrarian Reform (DAR) Municipal Office in Goa, Camarines Sur to
facilitate the processing of certain requirements as regards her
properties which was then subjected to DAR coverage pursuant to
pertinent agrarian laws and rules;

5. That she surrendered the owner’s duplicate copy of the above-

mentioned land to the said DAR office;

6. That during the later part of the 1980s, I was able to inquire with said
DAR office if they have on their file the owner’s duplicate copy of said
lot;

7. That to my dismay, I was informed by said office that they could not
find the owner’s duplicate copy of said lot despite diligent efforts to find
the same such that I believed that it was already lost beyond recovery;

8. That to the best of my personal knowledge the copy of OCT No. RO-449
(899) has not been subject to security for loan, delivered to another
person or entity to guarantee or incur any obligation or conveyance;

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

foregoing and for the purpose of filing the appropriate petition for re-
 issuance of owner’s duplicate copy of OCT No.RO-449 (899) and for
other lawful purposes.

IN WITNESS WHEREOF, I have hereunto set my hand this

_____________ at _____________, Philippines.

FLORENTINO PERPETUO P. REQUINTA, JR.

AFFIANT

SUBSCRIBED AND SWORN to before me, this _____________, by the

Affiant who has shown to me his_____________________ as competent proof
of his identity.

NOTARY PUBLIC

Doc. No. ______;

Page No. ______;
Book No.______;
Series of 20____.