Republic of the Philippines)

Province of Antique ) S.S.

Municipality of San Jose )
X------------------X

                                                   

AFFIDAVIT OF LOSS

I, _________________ of legal age, married, Filipino Citizen with

residence at _________________, after having been sworn to in accordance
with law, hereby depose and say that:

1. I was previously married to a certain ____________, and our marriage

was terminated last 2018 by reason of his death.

2. During our marriage, we had two children namely: Mr. ABC .and Mr. XYZ.

3. That during our marriage, I was in charge in safekeeping the pertinent

family records such as Birth Certificates, Passports, and land titles.

4. Sometime last 2023, it has come to my knowledge, that my previous

husband was the registered owner of two parcels of land aptly described
as:

A parcel of land described to be covered by Original

Certificate of Title No. 123445, further described as Lot No.
123445, with an area of Ten Thousand Seven Hundred Fifty-
Six (10, 756) Square meters more or less, located at
________, owned and registered in the name of
__________.

-and-

A parcel of land described to be covered by Original

Certificate of Title No. 67890, further described as Lot No.
7890, with an area of Ten Thousand Seven Hundred Fifty-
Six (10, 756) Square meters more or less, located at
________, owned and registered in the name of
__________.

5. I took earnest efforts to determine the whereabouts of the above-

mentioned title on our family records but to no avail. I even asked the help
of the other members of my household and tried to search for it on our
residence. I suspect that we might have misplaced it; hence, I gave up
and considered it as lost.

6. I execute this affidavit to attest to the truthfulness and veracity of the

foregoing facts, and for the purpose of securing another Owner’s
Duplicate Copy of Title of the above-mentioned titles of the parcels of
land, and for whatever purpose it may serve.

1
 IN WITNESS WHEREOF, I have hereunto set my hand this day,
__________________, at San Jose de Buenavista, Province of Antique,
Philippines.                 
                 

                                                                 _____________________
Affiant
        

  SUBSCRIBED AND SWORN to before me on the date and place above

stated by affiant______________, who have satisfactorily proven to me her
identity through her __________________, to be the same person who
presented and personally signed before me this Affidavit of Loss and attested
that the contents thereof are true and correct; and that she voluntarily executed
the same.

Doc. No. ____;

Page No. ____;
Book No. ____;
Series of 2023