Republic of the Philippines)

Province of Southern Leyte) s.s.

Municipality of S OGOD )
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AFFIDAVIT OF LOSS

I,CATALINA DE BELEN SANTOS, of legal age, Filipino and a resident of Brgy.

Bugasong, Libagon, Southern Leyte, after having been duly sworn to an oath in accordance with
law, hereby depose and say:

1. That I am the buyer of two parcels of land situated in Brgy. Kawayan, Libagon,
Southern Leyte from Mr. Reginaldo T. Gozo; evidenced therewith is a copy of Deed
of Absolute Sale, attached hereof and marked as annex “A”;

2. That relative for the transfer of declared owners and for the payment of appropriate
taxes with the Bureau of Internal Revenue (BIR), I entrusted and delegated the late
Arsie Pamalaran, Municipal Assessor of Libagon, Southern Leyte to process on my
behalf;

3. That, I was able to pay the Taxes due pertaining to the said transfer. A Certificate
Authorizing Registration, Official Receipts and other Documents from the BIR were
issued in my favor sometimes on year 2014;

4. Unfortunately, Arsie Pamalaran died without completing the entrusted authorities;

5. Upon his death, I demanded from his surviving spouse and his staffs in the Municipal
Assessors Office the copies of my documents, CAR, and the Official Receipts.
However, the aforementioned documents, CAR, and Official Receipts cannot be
found;

6. That we exerted an exhaustive efforts to locate the same but our search proved futile
as we could not locate the same up to the present;

7. That I executed this affidavit in order to attest to the truth and veracity of the
foregoing so that a copy of the said CAR be issued or I can proceed for the transfer
declared owners of my purchased properties and for whatever legal intents and
purposes this may serve.

IN WITNESS WHEREOF, I have hereunto set my hand ______________ in the

Municipality of Sogod, Southern Leyte, Philippines.

CATALINA DE BELEN SANTOS

Affiant

SUBSCRIBED AND SWORN to before me this _____________ at Sogod, Southern

Leyte, Philippines.