REPUBLIC OF THE PHILIPPINES)

_________________________) s.s.

AFFIDAVIT OF LOSS

I, __________________________, of legal age, single, Filipino, and a resident

of__________________________________, after having been sworn in accordance with law, hereby
depose and state –

1. I am the registered owner for the herein described property containing an area of one hundred forty
one (141) sq. meters more or less and covered by TCT No. T-728772 of Registry of Deeds for Calamba
Laguna;
Transfer Certificate of Title No. _______________
Registry of Deeds for the Calamba City

A parcel of Land x x x .

2. I have hereunto attached as ANNEX A the Special Power of Attorney issued

_______________________ in –Fact for this purpose of reconstituting the original copy of Owner’s
Transfer Certificate of Title which she acknowledged before ________________

3. The Registered Owner has openly possessed the subject house and lot and has openly exercised and
maintained all rights of ownership thereon.

4. I and the Registered Owner were looking for the original copy of Owner’s Copy of Transfer Certificate
of Title last December 2017 and we found that we can no longer find the Owner’s Original Copy of title
from the files. I and the Registered Owner exerted all diligent efforts to locate and retrieve the Owner’s
Original Copy of title and our effort resulted in vain, hence for all legal intents and purposes it is now
deemed lost and beyond recovery.

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5. I certify and confirm that the parcel of land covered by Transfer certificate of Title
No_________________________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.

6. 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 set my hand this ______________________ at ________________.

______________
Affiant

\\Subscribed and Sworn to before me this __________________________ at ____________________

Doc. No. ______ Notary Public

Page No. ______
Book No. ______
Series of _______

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