AFFIDAVIT OF LOSS

I, _____________. of legal age, married and a resident of _____________, Negros

Occidental, Philippines, under oath, depose and say that:

1. I have in my possession the Owner’s Duplicate Copy of Transfer Certificate of Title No.
_______registered in my name for safekeeping;

2. I diligently searched for the Owner’s Duplicate Copy of TCT No. T_______, if the same
is still in my house, my room or in my car or wherever I might have possibly placed it, but
up to the execution of this affidavit, my efforts have been in vain;

3. Hence, I have no choice but to declare that the Owner’s Duplicate Copy of TCT No. T-
_________ is considered lost for all legal intents and purposes;

4. This AFFIDAVIT OF LOSS is being executed to attest to the truth of the matters herein
stated.

SIGNED this __________________ in the City of Bacolod, Philippines.

_______________.
Affiant

REPUBLIC OF THE PHILIPPINES)

CITY OF BACOLOD )S.S
x- - - - - - - - - - - - - - - - - - - - - - - - - - - - x

SUBSCRIBED AND SWORN to before me this ____________________ in the City of

Bacolod, Philippines by the AFFIANT who exhibited to me the following competent evidence of
identity: ___________

Doc. No. _____;

Page No.______;
Book No. _____;
Series of 2018