REPUBLIC OF THE PHILIPPINES )

PROVINCE OF PANGASINAN )
CITY OF SAN CARLOS ) S.S

AFFIDAVIT OF LOSS

We, ROBERTO E. MATALOG and ELEUTERIA E. MATALOG, both of legal age, married, both
Filipinos, and residents of 027 Luna St. Tuy, Batangas, after being sworn in accordance with law
hereby voluntarily depose and say that:

1. We are the registered owners of a parcel of land located at Brgy. Baldog, San Carlos City,
Pangasinan, containing an area of Twenty-Four Thousand Seven Hundred Eighty square
meters (24,780 sqm) more or less, covered by Transfer Certificate Title No. 030-2021001476
of the Registry of Deeds of San Carlos City, Pangsinan from the canceled Transfer Certificate
of Title No. 40283;

2. Sometime on the 16th day of February 2023 there was a hold-up robbery incident in the
branch office of Tuy and Community Multi-Purpose Cooperative- JOSEFINA VILLAGE located
in 89 Mabini (Poblacion)San Carlos City, Pangasinan where all the contents of the safety
vault were forcefully taken including the original copy of the aforementioned title;

3. We are executing this Affidavit to attest the truth of the foregoing statements and to request
the issuance of new Certified True Copy of the Transfer Certificate of Title No. 030-
2021001476 in lieu of the one which was lost.

AFFIANT FURTHER SAYETH NAUGHT.

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

.

ROBERTO E. MATALOG and ELEUTERIA E. MATALOG

Affiants

SUBSCRIBED AND SWORN to before me this , affiants exhibited

to me their Competent Evidence of Identity by way of issued at
on .

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