REPUBLIC OF THE PHILIPPINES)

CITY OF __________________) S.S.

x---------------------------------x

AFFIDAVIT OF LOSS

I, _____________________________, of legal age, single, Filipino, and with residence

at _______________________________, after being duly sworn to in accordance with
law, depose and state THAT:

1. I am the registered owner of a parcel of land situated in

________________________________, as evidenced by Transfer Certificate of
Title (TCT) No. ______________________ issued by the
______________________ of ___________________, containing an area of
______________________________ (_____) Square Meters, more or less;

2. (Fact);

3. Despite diligent efforts to locate said luggage, the same could not be
found and is now beyond recovery;

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 for all lawful intents and purposes it may
serve.

IN WITNESS WHEREOF, I have hereunto set my hand

this ___________________ in ___________ City, Province of
_____________, Philippines.

_________________________________
(NAME OF AFFIANT)
Affiant

BEFORE ME A NOTARY PUBLIC for and in the above jurisdiction

personally appeared, _____________________________ with his/her competent
evidence of his/her Identity _______________________, known to me to be the same
person who executed the foregoing instrument which he acknowledged to be
his/her free act and deed.

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 20___.