AFFIDAVIT OF LOSS

I, xxx, of legal age, Filipino and a resident of Bacolod City, Negros Occidental, under
oath, depose and say that:

<1> I am the lessee of a parcel of land located at Bacolod City, Negros Occidental.
As evidenced by Transfer Certificate of Title No. 000000000 issued by the Register of
Deeds of Bacolod City, containing an area of Two Hundred Eighty square meters (280),
more or less, more particularly described as:

TRANSFER CERTIFICATE OF TITLE NO. 000000000

A PARCEL OF LAND. X X X X CONTAINING AN AREA OF TWO HUNDRED

EIGHTY (280) SQUARE METERS, MORE OR LESS.

<2> The Owner’s Duplicate Copy of Transfer Certificate of Title No. 092-
2013008756 was given to me by the lessor Jimmy G. Panlilio when I leased the said
property. When I was about to have my right as a lessee annotated at the back of Transfer
Certificate of Title No. 0000000, I could no longer find the Owner’s Duplicate Copy. I
searched for the Owner’s Duplicate Copy of Transfer Certificate of Title No. 000000 among
my personal files at home, where I usually kept my records, and wherever I could have
placed it but the same could not be found;

<3> I do not recall giving the Owner’s Duplicate Copy of Transfer Certificate of
Title No. 0000000 to any person or entity for any reason whatsoever. Neither has it been
forfeited nor cancelled;

<5> In view of the foregoing, I am constrained to declare that the Owner’s

Duplicate Copy of Transfer Certificate of Title No. 000000 issued by the Register of Deeds
of Bacolod City is lost for all legal intents and purposes;

<6> 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.

xxx
Affiant
Republic of the Philippines)
CITY OF BACOLOD )S.S.
x - - - - - - - - - - - - - - - - - - - -x

SUBSCRIBED AND SWORN to before me this _________________ in the City of Bacolod,

Negros Occidental, Philippines. AFFIANT exhibited to me his competent evidence of
identity written below his name.

Doc. No. ______;

Page No. ______;
Book No.______;
Series of 2019.