REPUBLIC OF THE PHILIPPINES)

CITY OF TAGBILARAN                      ) S.S.

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AFFIDAVIT OF CANCELLATION OF THE FIRST APPLICATION
WITH STATEMENT OF NO CERTIFICATE OF TITLE RECIEVED

        I, JOVELYN P. BLAZELY of legal age, Filipino, and a resident of Aguipo, Mabini, Bohol, Philippines, after
having been duly sworn to in accordance with law, depose and state:

1. That I am the lawful owner and possessor of over a parcel of land designated as Lot No. 4812
containing an area of TWO THOUSAND TWO HUNDRED EIGHTY square meters located at
Aguipo, Mabini, Bohol;

2. That the said parcel of land is bounded on the North by a Creek; on the East by Lot 30(4811);
on the South by Lot 29(4801); and on the West by Lot 20(4813);

3. That I acquired the said parcel of land on January 15, 2016 through an Extrajudicial Settlement
with Simultaneous Sale of Land which was notarized and entered in his Notarial Book as Doc.
No. 234, Page No. 47, Book No. 81 Series of 2016 by Atty. Thaddeus Jose C. Acero;

4. That on the same year I applied for titling of the said land at the Office of the Municipal Assessor
of Mabini;

5. That due to my busy schedule I forgot to follow-up my application and believing that the first
application was cancelled by my inaction I filed another application;

6. That as a consequence, I have two application pending at the Office of the Municipal Assessor
of Mabini ;

7. That I will forego and cancel my first application and will continue my second application;

8. That I did not received any document or title transferring the said land to my name;

9. That I execute this affidavit voluntarily to attest to the truth of the foregoing statements to
support my insurance claim, and for all legal purposes it may serve.

IN WITNESS WHEREOF, I have hereunto affixed my signature on this 6th of September 2018 in the
City of Tagbilaran, Province of Bohol, Philippines.

JOVELYN P. BLAZELY
Affiant
VALID ID NO/ DL NO. ______________
Issued by: ________________________
Expiration date: ________

SUBSCRIBED AND SWORN to before me this 6th day of September 2018 in the City of Tagbilaran,
Bohol, Philippines. Affiant exhibited to me his competent proof of identity previously written.

Doc. No. ________;

Page No.________;
Book No.________;
Series of 2018.