REVOCATION OF AFFIDAVIT OF LOSS

KNOW ALL MEN BY THESE PRESENTS:

WHEREAS, under date of July 5, 2018, I, ____________________, have executed an

Affidavit of Loss, for the supposed loss of a land title registered under my name, located at Sta.
Rosa, Mun. of Concepcion, Province of Tarlac, containing an area of TWENTY FOUR
THOUSAND NINE HUNDRED FIFTY THREE (24,953) square meters, more or less, and
covered by TCT No.: 418141 of the Registry of Deeds for the Province of Tarlac which was
ratified before Atty. ______________________, Notary Public in and for ________________,
as per Doc. No. ________, Page. No. __________ Book No. _______________, Series of
_____________ of his Notarial Register; and

NOW, THREFORE, I have revoked, countermanded, annulled and made void, and by
these presents do revoke, countermand, annul and make void the said Affidavit of Loss.

IN WITNESS WHEREOF, I have hereunto set my hand at ________________, on this

______ day of ______________, 20______.

_____________________
Affiant

SIGNED IN THE PRESENCE OF:

___________________________     ___________________________

ACKNOWLEDGMENT

REPUBLIC OF THE PHILIPPINES)

TARLAC CITY )  SS.

BEFORE ME, a Notary Public for and in the City of Tarlac, this 3 rd day of July 2018, appeared
all the foregoing parties who satisfactory proven their identities through their respective
identification cards and acknowledged before me that this DEED ids their own free and
voluntary act.

This instrument, consisting of one (1) page, including the page on which this acknowledgment is
written, has been signed on the left margin of each and every page thereof by the concerned
parties and their witnesses, and sealed with my Notarial Seal.
 

WITNESS  MY HAND AND SEAL on the date and Place above written.

Notary Public
Doc. No. ........;
Page No. .......;
Book No. .......;
Series of 2018.