REPUBLIC OF THE PHILIPPINES )

Province of ) S.S.

AFFIDAVIT

I, (name), (citizenship), of legal age, with residential address at (residential

address), after having been duly sworn in accordance with law, hereby depose and say
that:

1. I am the registered owner of a real property situated in (location of lot), covered

by Transfer Certificate of Title No. (title no.) by the Registry of Deed of
(City/Province);

2. The Owner’s Duplicate Copy of the Transfer Certificate of Title covering the
above mentioned real property was lost/missing from my files (Reason of loss);

3. The real property covered by the said Transfer Certificate of Title has not been
encumbered, mortgaged, pledged, sold, donated or otherwise alienated, nor the
subject of any power or authority granted to anyone;

4. Despite diligent efforts to look for the said Owner’s Duplicate Copy of the
Transfer Certificate of Title, all my efforts proved futile and in vain, thus I am
declaring it a loss.

5. I am executing this Affidavit to attest to the truth of the foregoing and for
whatever legal purpose it may serve, including to request the Office of the Registry
of Deed of (City/Province) to annotate this affidavit and for my petition with the
court for the issuance of another Owner’s Duplicate Copy of the Transfer Certificate
of Title in lieu of the one that was lost.

IN WITNESS WHEREOF, I have hereto affix my signature this ____ day of

_______________ 20__ at ____, Philippines.

Affiant

SUBSCRIBED AND SWORN to before me this _____ of ______________ 20__ at

Ramon, Isabela, affiant exhibiting to me his __, valid until__.

Notary Public
Doc. No. _______
Page No. _______
Book No. _______
Series of 20