REPUBLIC OF THE PHILIPPINES)

CITY OF ILOILO ) S.S.

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

AFFIDAVIT OF LOSS

I, ______________, of Legal Age, Filipino, married, with residential address at Brgy.

_______________________ subscribing under oath, hereby depose and state:

• That my father ______________ have been issued an owner’s duplicate copy of

Emancipation Patent title No. _____________;

• That sometime on _______________, I could no longer find the said Emancipation

Patent Title inside the cabinet of our parents;

• Efforts were exerted to locate said owner’s duplicate copy of Emancipation Patent title
No. ___________, but in spite of diligent search, it could not be found and the
same is now beyond recovery;

• As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing and
to support my application for the issuance of a new copy of Emancipation Patent
title No. ____________ in lieu of the one that was lost.

IN WITNESS WHEREOF, I have hereunto set my hand this ____________________

in Iloilo City, Philippines.

Affiant

SUBSCRIBED AND SWORN TO before me this __________________ in

___________________, Philippines, affiant exhibiting to me his competent evidence of
identity by way of _______________________ issued at _________________ on
__________________.

Doc. No. _______;

Page No._______;
Book No._______;
Series of 2020.